What is the appropriate course of action for a pregnant woman with intellectual disability (ID) and an Intelligence Quotient (IQ) of 80 who wants to continue her pregnancy, despite her mother's request for an abortion?

Management of Pregnancy Decision-Making in a Woman with Intellectual Disability

The appropriate course of action is to refuse to perform an abortion (option A) and respect the patient's expressed wish to continue her pregnancy, as a patient with an IQ of 80 generally has the capacity to make her own reproductive decisions. 1

Understanding Decision-Making Capacity

An IQ of 80 falls within the borderline intellectual functioning range, not moderate or severe intellectual disability. According to the Society for Maternal-Fetal Medicine (SMFM), patients with this level of cognitive functioning typically have the ability to:

• Understand basic information about pregnancy and childbirth
• Communicate a choice (which the patient has clearly done)
• Appreciate the situation and its consequences
• Reason about treatment options 1

This patient has expressed a clear desire to continue her pregnancy, which must be respected as long as she demonstrates decision-making capacity.

Ethical Considerations

Several key ethical principles support respecting this patient's autonomy:

• Respect for autonomy: The SMFM emphasizes respecting pregnant individuals' autonomy to make decisions aligned with their core values 1
• Informed decision-making: Patients should receive counseling on all management options 1
• Justice: Equitable care requires not discriminating against patients based on intellectual disability when they demonstrate capacity 1
• Avoiding reproductive coercion: Healthcare providers must provide balanced information about all options 1

Appropriate Next Steps

1. Assess decision-making capacity specifically for this pregnancy decision

   • Evaluate understanding of pregnancy, childbirth, and parenting responsibilities
   • Document capacity assessment thoroughly

2. Provide appropriate counseling

   • Information about maternal and fetal health risks
   • Available support services
   • Strategies to optimize pregnancy outcomes

3. Develop a support plan

   • Identify what additional resources might benefit the patient
   • Consider involving social services (not to remove decision-making authority but to provide support)
   • Ongoing assessment of understanding and needs throughout pregnancy

Why Other Options Are Inappropriate

• Option B (Perform abortion as patient is not competent): This violates the patient's autonomy and incorrectly assumes lack of capacity based solely on IQ 1
• Option C (Obtain court order): Court intervention is unnecessary when a patient demonstrates capacity to make her own decisions 1
• Option D (Call child protective services): Premature and inappropriate as the pregnancy is ongoing and no child neglect or abuse has occurred

Important Considerations

• Intellectual disability exists on a spectrum, and an IQ of 80 is at the mild end
• Decision-making capacity is decision-specific and should not be generalized across all areas of life
• Support for decision-making does not mean making decisions for the patient
• The patient may benefit from decision support tools and clear communication while still maintaining her autonomy 1