An expert-driven consensus framework for the study of potentially morally injurious events and their impacts: findings from an e-Delphi study

Abstract

Background: Moral injury (MI) refers to the profound psychosocial, spiritual and behavioural impacts of exposure to potentially morally injurious events (PMIEs). Despite growing recognition of MI across military and civilian contexts, definitional clarity surrounding PMIEs remains limited. Objective: This study applied e-Delphi methodology to generate consensus on the defining features of PMIEs and their impacts among an interdisciplinary panel of MI experts. Method: The panel first provided narrative responses to open-ended questions on defining PMIEs. These were refined into 63 Likert statements. Experts rated agreement on these and completed card-sort and ranking exercises. Results: Statements addressed eight themes: exposure, transgressive acts, consequences of PMIEs, trauma vs. PMIEs, moral agency, betrayal, subjectivity, and high-stakes. Consensus (≥80% agreement) was reached for 55% of all statements. Consensus for card-sort and ranking exercises was also observed, pertaining to etiological mechanisms of MI, and risk and protective factors. Themes with the highest levels of consensus included exposure and transgressive acts, while moderate consensus was achieved on PMIE consequences and comparisons to trauma. Lower consensus emerged around moral agency, betrayal, high-stakes and subjectivity, substantiating these as areas of ongoing debate. Conclusions: This study clarifies key definitional features of PMIEs and their impacts, with findings organised into a consensus framework for the future study of PMIEs. Findings highlight the need for empirical testing of proposed features and areas of debate, integration with emerging trauma frameworks, and culturally inclusive approaches