Healthcare ethics education is commonly evaluated through knowledge, moral sensitivity, confidence, or performance in educational exercises. These outcomes do not establish whether learning alters clinical deliberation when learners encounter hierarchy, uncertainty, competing obligations, time pressure, role modelling, or organizational constraints. A realist account is therefore needed to explain how educational resources interact with learner reasoning, supervision, and workplace conditions. To explain for whom, in what educational and clinical contexts, through which mechanisms, and under what supervisory and organizational conditions healthcare ethics education contributes to changes in clinical deliberation and ethically consequential action. A realist review was undertaken using iterative searching, theory development, relevance and rigour assessment, and context–mechanism–outcome analysis. Five targeted PubMed-domain searches were conducted on 22 September 2026 across ethics and bioethics education, moral and ethical sensitivity, simulation and reflective pedagogies, hidden curricula and professionalism, ethical climate, supervision, and realist health-professions education. The accessible search interface displayed 60 records; two duplicated records were removed, leaving 58 unique records, of which seven fell outside the 2018–2026 date window. Figure 1 presents the documented search and date-screening stages through 51 date-eligible unique records. Analysis distinguished proximal educational change from persistence, supervised enactment, workplace transfer, and clinical action. Ethics education most consistently altered proximal deliberative resources when learners actively rehearsed ethical reasoning through simulation, debate, role play, structured reflection, or dilemma analysis. Effects were neither uniform nor necessarily durable. Programme responses depended on whether learners experienced psychological safety, credible supervision, structured feedback, time for interpretation, and opportunities to articulate competing reasons. Transfer into clinical action was further conditioned by ethical climate, role modelling, hierarchy, organizational permission, and whether learners could exercise newly developed capabilities without unacceptable interpersonal or institutional cost. Moral sensitivity, confidence, professional identity, and assessment performance functioned as intermediate indicators rather than equivalent measures of ethical action. Healthcare ethics education is most plausibly effective when educational resources activate reflective and relational learning mechanisms that are subsequently reinforced through credible supervision and organizational conditions that permit ethical reasoning to influence practice. Educational exposure alone is insufficient to establish durable change in clinical deliberation.
