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

Moral injury refers to the deep pain that someone feels because of past experiences that went against their personal sense of right and wrong (such as their own actions or seeing something happen that they couldn’t or didn’t stop). Moral injury can significantly impact mental health.

What is this research about?

In recent years, there has been more research trying to better understand moral injury, including in military and Veteran populations. However, there still isn’t clear agreement about what moral injury is and the events that may cause it (which are referred to as “potential morally injurious events” or PMIEs). This lack of clarity has hindered progress in research, as well as support options for moral injury.

What did the researchers do?

To help advance research on moral injury, this study worked with international moral injury experts, including people with lived experience of moral injury, to define the key features of PMIEs and their impacts. The researchers asked the experts to answer open-ended questions related to PMIEs and then organized their answers into 63 statements. The experts were then asked to rate their agreement for each statement on a scale, and the researchers examined the responses to identify key areas of agreement and focus.

What did the researchers find?

• Eight main themes emerged from the experts’ opinions on moral injury and PMIEs. The 63 statements assessed by the experts were organized into the following themes:
  1. Exposure: the features of events that can give rise to moral injury.
  2. Transgressive acts: types of actions that go against moral values.
  3. Consequences: the emotional and psychological impacts of PMIEs.
  4. Trauma vs. potentially morally injurious events: how do they differ?
  5. Moral agency: who is responsible for a transgressive act?
  6. Betrayal: what it is and how does it relate to PMIEs and moral injury?
  7. Subjectivity: how personal interpretation influences PMIEs and moral injury.
  8. High-stakes situations: the features of high-stakes scenarios and their relevance to defining PMIEs.
• The experts reached consensus on 55% of all statements with:
  • strong agreement on the themes of exposure and transgressive acts;
  • moderate agreement on the themes of consequences and how potentially morally injurious events compare to trauma; and
  • less agreement on the themes of moral agency, betrayal, high-stakes, and subjectivity.
• Building on the strongest areas of expert agreement, the researchers proposed a framework to guide future research and help health providers, leaders, and others to better identify moral injury.
• Findings from this work could help improve how we understand, research, and respond to moral injury.

Source

Houle SA, Birch M, Murphy D, Greenberg N, Nazarov A, Richardson JD, (2026). An expert-driven consensus framework for the study of potentially morally injurious events and their impacts: Findings from an e-Delphi study. European Journal of Psychotraumatology.