The hospital code blue alarm is supposed to signal urgency — a rush of medical professionals fighting to pull a patient back from the brink. But in certain rooms, the performance is more muted. Doctors walk, not run. Chest compressions are half-hearted. Epinephrine might be prepared but not pushed. The ritual continues, but with no real intent to reverse death.

It’s called a “slow code.” On the surface, it looks like standard CPR, but in reality the medical staff isn’t really trying to save the patient — they’re staging the appearance of resuscitation, often because they’ve been cornered by policy, family expectations, or legal threat.

It’s not like the doctors and nurses aren’t interested in doing their jobs and following their oath. The deliberate tepid attempt at resuscitation is done for show because they know the patient has no chance of making it and CPR would only inflict much pain during the patient’s last moments. It’s a deception, yes — but also, perhaps, a mercy.

For decades, slow codes have been condemned by bioethicists as dishonest and unethical. The standard has been clear: don’t fake it. If CPR is inappropriate, don’t do it. If it must be done, do it properly.

But what if the system forces doctors to take part?

A new wave of scholarship suggests we’ve misunderstood the slow code. Drawing on fresh data, historical context, and ethical theory, researchers argue that these quiet performances are not just common — they may be morally defensible, even necessary. It’s an ethical gray zone, one that reveals how hard it is to program decency into an operating system not designed for nuance.

A System That Defaults to Resuscitation

Cardiopulmonary resuscitation (CPR) is one of medicine’s most iconic acts. Since it was formally introduced in 1960, CPR has become a standard procedure in hospitals worldwide. But its widespread use has drifted far from its original purpose.

“CPR was initially used very selectively at the discretion of clinicians,” writes Stuart McLennan, a medical ethicist at the Technical University of Munich. But by the 1980s, it had become “the required default position for all patients having cardiac arrest in the hospital.”

That default persists today. If a patient doesn’t have a Do Not Resuscitate (DNR) order, clinicians are expected — legally and ethically — to perform CPR. Yet, studies have shown that in as many as 85% of in-hospital resuscitations, the intervention is medically futile or not in the patient’s best interest. Patients often survive only to die days later, with broken ribs, brain damage, or in deep sedation.

Hospitals introduced DNR orders as a solution, allowing patients or physicians to decline CPR in advance. But the system remains inconsistent and reactive. “Patients are not obliged to do an advance directive,” McLennan writes. “And the extent to which physicians draw up treatment plans…is at their discretion.”

The result is that CPR is often performed reflexively, even when it defies logic or compassion.

What Is a Slow Code, Really?

A slow code is not one thing. It’s a spectrum of practices — sometimes a slight delay in response, sometimes chest compressions that are deliberately ineffective. As ethicists Elizabeth Andrist and colleagues argue in the Bioethics issue, the term refers “broadly to any insincere attempt at cardio-pulmonary resuscitation.”

Critics have long condemned slow codes as violations of trust. They’re deceptive, potentially fraudulent, and may suggest that doctors are choosing who lives and who dies behind closed doors. But isn’t that a bit too harsh? Recent empirical studies reveal a more complicated picture. One study found that nearly half of critical care physicians surveyed believed slow codes are ethical in some circumstances. Nurses — often the most morally attuned members of a care team — shared similar views.

For some practitioners, slow codes offer a last resort: a way to avoid the cruelty of aggressive CPR while sparing families the trauma of watching a loved one die without any visible effort. “Slow codes provided one way out of the impossible morass for us,” writes physician Paula Mayer, reflecting on her experiences in the 1980s. “Almost nobody died back then without being coded, and it seemed like everybody who coded died.”

When Policy Collides with Morality

The persistence of slow codes, according to McLennan and colleagues, is not an ethical failure of individuals but a symptom of broken CPR policy.

Their argument is blunt: hospital policies that mandate CPR by default, without requiring clinicians to assess whether it is medically indicated, are both ethically and legally inappropriate. “Requiring CPR in circumstances where all involved agree that it is not in the patient’s best interests is ethically inappropriate,” they write. Worse, it may be unlawful in jurisdictions where treatment without consent must be demonstrably beneficial.

Why does this default persist? The answer, partly, lies in fear. “Physicians often lack the freedom to say ‘no,’” wrote Jason Wasserman and Parker Crutchfield in Stat News. “Litigious families, judicial orders, and the constraints of state law sometimes put them in an impossible situation.”

In such no-win scenarios, the slow code becomes a kind of ethical disobedience. Wasserman calls it “a quiet act of resistance in defense of decency, compassion, and good medicine.”

Still, not everyone agrees. Critics worry that legitimizing slow codes opens the door to abuse — inviting doctors to make unilateral decisions in secret, especially for vulnerable patients. Transparency, they argue, is a cornerstone of medical ethics. And no matter how well-intentioned, deception may corrode trust in healthcare.

But defenders see the slow code as a tragic compromise. “We think the literature on slow codes has been dogmatic and incompletely theorized,” Crutchfield and Wasserman write in their editorial. “The articles in this special issue pull up that anchor.”

For some ethicists, the real problem isn’t the slow code itself, but the failure to reckon with why it exists. Policies have created a system where doctors perform CPR not because it will help, but because they’re afraid not to.

Where Do We Go From Here?

The solution, according to McLennan and others, is systemic reform. Advance care planning must become routine. Hospital policies should allow doctors to assess in real time whether CPR is appropriate. And most critically, clinicians must be empowered to make decisions based on a patient’s best interest, not just fear of liability.

Medicine is not about forestalling death at all costs, McLennan writes. “It is about helping people live as healthily as possible within a finite lifespan.”

Until that shift occurs, slow codes will continue at the edge of life and death. Not because doctors want to deceive, but rather because all eyes are on them and the performance is expected even in the most futile of situations.

The debate around “slow code” was recently covered in a special issue of the journal Bioethics.