Respecting Patient Autonomy in Reproductive Decision-Making
The appropriate action is to refuse to perform the abortion (option A) as the patient has expressed her desire to continue the pregnancy and has the capacity to make this decision despite her intellectual disability.
Assessment of Decision-Making Capacity
An IQ of 80 falls within the borderline intellectual functioning range, not moderate or severe intellectual disability. This level of cognitive function generally allows for:
- Understanding of basic information about pregnancy and childbirth
- Ability to communicate a choice (which she has clearly done)
- Appreciation of the situation and its consequences
- Reasoning about treatment options 1, 2
Ethical and Legal Framework
The Society for Maternal-Fetal Medicine (SMFM) emphasizes several key ethical principles that apply directly to this case:
- Respect for autonomy: Clinicians should respect pregnant individuals' autonomy to make decisions that best align with their core values after appropriate counseling 3
- Informed decision-making: Patients should receive counseling on all management options to ensure they can make an informed decision 3
- Maternal priority: While maternal medical benefit takes priority when maternal and fetal benefit conflict, the pregnant patient may exercise their autonomy by choosing to prioritize perceived fetal benefit 3
Appropriate Management Approach
Respect the patient's expressed wishes: The patient has clearly communicated her desire to continue the pregnancy, which must be respected as long as she has decision-making capacity 3
Provide appropriate counseling: Ensure the patient receives information about:
- Maternal and fetal health risks of pregnancy
- Available support services
- Strategies to optimize pregnancy outcomes 3
Assess support systems: Evaluate what additional support the patient might need during and after pregnancy, including:
- Social services referrals
- Parenting resources for individuals with intellectual disabilities
- Family support systems 4
Why Other Options Are Inappropriate
Option B (Do abortion as patient is not competent): This violates the patient's autonomy. An IQ of 80 does not automatically render someone incompetent to make medical decisions 2, 5
Option C (Obtain court order): Seeking a court order to override the patient's wishes would be appropriate only if there was clear evidence the patient lacked decision-making capacity, which is not indicated by an IQ of 80 alone 6
Option D (Call child protective services): This would be premature and inappropriate as there is no child yet, and having an intellectual disability does not automatically make someone an unfit parent 4
Important Considerations
Avoid reproductive coercion: Healthcare providers must provide balanced information about all options to reduce the likelihood of reproductive coercion 3
Support decision-making: Individuals with intellectual disabilities may benefit from decision support tools and clear communication, but this doesn't mean making decisions for them 5
Ongoing assessment: Continue to assess the patient's understanding and needs throughout pregnancy to ensure appropriate support is provided 3
The SMFM guidelines clearly state that justice requires providing equitable care to all pregnant individuals and not treating pregnant patients differently simply because they are pregnant 3. This principle extends to not discriminating against patients based on intellectual disability when they demonstrate capacity to make their own reproductive decisions.