What is the appropriate course of action for an intellectually disabled pregnant woman with 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 an Intellectually Disabled Woman

The appropriate course of action is to refuse to perform an abortion (Option A) when an intellectually disabled pregnant woman with an IQ of 80 expresses her desire to continue the pregnancy, despite her mother's request for termination. 1

Understanding Decision-Making Capacity

Patients with borderline intellectual functioning (IQ of 80) generally maintain the ability to:

• Understand basic information about pregnancy and childbirth
• Communicate their choices
• Appreciate their situation and its consequences
• Reason about treatment options 1

The Society for Maternal-Fetal Medicine (SMFM) emphasizes respecting pregnant individuals' autonomy to make decisions that align with their core values after appropriate counseling 2. This principle applies regardless of intellectual disability status, as long as the patient demonstrates decision-making capacity.

Ethical Framework for This Case

1. Respect for Patient Autonomy: The patient has expressed her desire to continue the pregnancy. This expressed wish must be respected as it represents her autonomous choice 1, 3.

2. Avoiding Reproductive Coercion: Performing an abortion against the patient's wishes would constitute reproductive coercion, which violates ethical principles of patient autonomy 1.

3. Justice in Healthcare: The principle of justice requires providing equitable care to all pregnant individuals without discrimination based on intellectual disability when they demonstrate capacity to make reproductive decisions 1.

Why Other Options Are Inappropriate

• Option B (Do abortion as patient is not competent): This option incorrectly assumes that an IQ of 80 automatically renders the patient incompetent. Borderline intellectual functioning does not equate to lack of decision-making capacity 1.

• Option C (Obtain court order): Seeking a court order to override the patient's wishes would be inappropriate when the patient has demonstrated capacity to make her own reproductive decisions 2, 1.

• Option D (Call child protective services): This option is premature and inappropriate as there is no child yet, and no evidence of immediate harm to justify involving protective services 1.

Appropriate Management Approach

1. Assess decision-making capacity specifically related to pregnancy decisions (not general intelligence)

2. Provide comprehensive counseling including:

   • Information about maternal and fetal health risks
   • Available support services
   • Strategies to optimize pregnancy outcomes 1

3. Document the patient's understanding of the information provided and her reasoning for continuing the pregnancy

4. Develop a support plan that addresses her specific needs during pregnancy and postpartum

Potential Pitfalls to Avoid

• Conflating intellectual disability with incapacity: An IQ of 80 alone does not indicate inability to make reproductive decisions 1

• Allowing third-party preferences to override patient autonomy: The mother's wishes should not supersede the patient's autonomy when capacity is present 2, 1

• Failing to provide adequate support: While respecting autonomy, ensure appropriate resources are in place to support the patient throughout pregnancy and beyond 1

• Using coercive practices: Healthcare providers must provide balanced information about all options without coercion 1, 4

By respecting this patient's expressed wishes to continue her pregnancy while providing appropriate support and counseling, healthcare providers uphold ethical principles of autonomy, beneficence, and justice in reproductive healthcare.