By: Clare Rigney
Published: November 3, 2026
Since the Dobbs decision, the web of reproductive healthcare regulations in the United States has only become more complex. Issues of hospital inaccessibility, confusion over Medicare or Medicaid coverage, and vague legal frameworks only compound for disabled individuals. Many disabled individuals rely on family members or legal guardians for important medical decisions related to contraception. Although guardians can have general medical decision-making authority, this often skirts uncomfortably close to the line of reproductive health care and family planning.[1] Those with physical disabilities do not always lack the mental capacities to make important medical decisions in their own best interest, but this problem arises more frequently with people who have mental disabilities.[2]
While disabled individuals are promised equitable access to health care via the Americans with Disabilities Act (“ADA”) and section 504 of the Rehabilitation Act, access is not guaranteed in practice.[3] The proposed Reproductive Health Care Accessibility Act seeks to improve this access.[4] Proponents of the bill address issues like travel barriers, lack of healthcare providers with training on disabled individuals’ needs, and the lower life expectancy of these individuals.[5] Access to abortion care is particularly at risk.[6] The Act advocates educating healthcare providers on the unique needs of disabled individuals.[7] However, the Act falls short of adequately addressing the needs of the most vulnerable of this population: mentally disabled people who rely on legal guardians to make medical decisions on their behalf.
Legal guardians of disabled individuals are responsible for the “medical or other professional care, counsel, treatment, or service” including withholding or withdrawing consent for medical care.[8] When seeking proper medical care, the guardian must “order any act necessary for the best interests of the disabled person.”[9] Aging and disability advocates use the National Guardianship Association’s Standards of Practice as a guide to evaluate guardian effectiveness, but this is not uniformly enforced.[10] Each state differs on the annual evaluation process for determining whether a legal guardian is upholding their responsibility to act in their ward’s best interest.[11] Some states are further divided.[12] Every state asks about residence and medical treatment decision-making, as well as the involvement of the disabled individual in decision-making, but only four states ask about a guardian’s ongoing training and education.[13]
Lawmakers have attempted to address the practical and professional issues of treating those with disabilities, like expanding education and training opportunities. Still, doctors, family, and guardians themselves may have preconceived misconceptions about mentally disabled people.[14] Paternalistic assumptions, like the belief that intellectually disabled people are incapable of consenting to sexual activity, can disrupt the possibility of collaborative decision-making regarding reproductive healthcare.[15] Occasional biases or misunderstandings can lead to limited access to reproductive healthcare or decreased quality of care. Some clinicians are anxious about conducting C-sections on clients because of decisions that must be made during the birthing process.[16] Some believe that a client’s health issues are hereditary or a result of their illness, resulting in misdiagnosis.[17] The clinicians might change planned reproductive care based on their own assumed probability of treatment success, inconsiderate of the ward’s desires.[18] In many of these situations, a legal guardian is expected to have either the loudest or the only voice in the room.
Every state has different rules on what powers a guardian possesses. In Wyoming, guardians must petition the court before a doctor is allowed to provide “long-term or permanent contraception” of the disabled individual.[19] Like judges granting a judicial bypass for minors who wish to control and assent to their own care, states have experimented with requiring court permission before guardians can take similar drastic measures.[20] These issues could also be addressed with further legal education for those who draft guardianship agreements and statutes, ensuring that “full” or “plenary” guardianship agreements are written with detailed stipulations on what sort of reproductive care the guardian can and cannot singularly consent to.[21]
International tribunals, such as the United Nations Convention on the Rights of Persons with Disabilities Article 12, endorse an alternative to guardianship called supported decision-making.[22] Supported decision making is a method of care that focuses on involving the ward in their own affairs, empowering them to make their own decisions with the dedicated assistance of chosen loved ones.[23] Advocates for this recognize that different wards require different assistance and recognize that more individualized and specific care is always better.[24] Some advocates go further, supporting a requirement that informed consent must be determined by a professional who has been trained to assist and communicate with disabled patients.[25]
The Reproductive Health Care Act is a respectable starting point for addressing the previous issues; however, it lacks important details related to the responsibilities of guardians. Helpful additions would address the copious state diversities regarding how they regulate legal guardianship. It could emphasize the importance of education, to lessen the negative impact of stereotypes on treatment concerning the sexual wellness of wards and their ability to give consent to procedures like IUD implantation or sterilizations. It could also further the doctrine of supported decision making, encouraging states and individuals to involve wards in their own important decisions. As the system stands, guardians have far too much power over their ward’s major life decisions, state systems are too diverse to provide fair treatment for mentally disabled people in all states, and the ample negative attributes must be addressed via some federal action.
[1] Marissa Ditkowsky, Choice at Risk: The Threat of Adult Guardianship to Substantive and Procedural Due Process Rights in Reproductive Health, 76.2 Nat. Lawyer’s Guild L. Rev. (2019).
[2] Id.
[3] H.R. 4901 § 2(4) – (5) (2023-2024).
[4] Id.
[5] Id.
[6] Id. at § 2(8).
[7] Id. at § 3-6.
[8] MD Ann. Code § 13-708 (b)(9)(i-iii).
[9] MD Ann. Code § 13-708 (d)(3)(iii).
[10] Joanne Tompkins, Heather Connors, & Diane Robinson, Seize the Data: An Analysis of Guardianship Annual Reports, 37 J. of Aging & Social Policy 3, 512, 516 (2023).
[11] See id. at 519 (providing examples of the type of questions asked of caregivers).
[12] See id. at 516 (identifying states in which evaluations vary by county, such as Alabama, California, Georgia, Indiana, Louisiana, Missouri, Mississippi, and Tennessee).
[13] Id. at 519.
[14] Anita Silvers, Leslie Francis, & Brittany Badesch, Reproductive Rights and Access to Reproductive Services for Women with Disabilities, 18 Am. Med. Ass’n J. Ethics 430, 431 (2016).
[15] Id.
[16] Id. at 432.
[17] Id.
[18] Id.
[19] Kaitlynn Milvert, How Adult Guardianship Law Fails to Protect Contraceptive Decision-Making Rights, Health Law Policy, Biotechnology, & Bioethics (Oct. 7, 2021).
[20] Id.
[21] Id.
[22] Id.
[23] Administration for Community Living, Alternatives to Guardianship, U.S. Dept. Health & Human Serv., https://acl.gov/programs/empowering-advocacy/alternatives-guardianship (last accessed Mar. 5, 2026).
[24] See id. (listing methods in which designated “trusted people” can aid disabled individuals on health, legal, and financial matters without receiving overarching plenary authority).
[25] Silvers, Francis, & Badesch, supra note 14, at 431.