Moral courage in health sciences students: a systematic review of challenges, influencing factors, and consequences

Moral courage is the critical bridge between ethical knowledge and ethical action in healthcare. While health sciences students often possess high moral sensitivity, they frequently struggle to act on their values due to the "theory-practice gap" and the pressures of clinical hierarchies. The suppression of moral courage not only compromises patient safety but is also closely associated with moral distress and professional burnout among trainees.

This systematic review aims to critically analyze the global evidence regarding the prevalence of moral courage among health sciences students and to identify the barriers, facilitators, and consequences associated with moral courage in educational settings.

This systematic review was conducted in accordance with PRISMA guidelines and registered in PROSPERO (CRD420251057915). A comprehensive search was performed across PubMed, Embase, Web of Science, the Cochrane Library, and Google Scholar to identify relevant studies published from 2000 to March 2025. The methodological quality of the included studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools.

A total of 21 studies, comprising 4,719 participants from diverse cultural contexts, were included. The findings reveal a disciplinary divergence in moral courage: nursing students generally exhibited moderate-to-high levels, whereas medical and dental students reported lower levels, often constrained by rigid hierarchies. The primary barriers identified were the "hidden curriculum," fear of negative evaluation, and hierarchical power dynamics. Conversely, key facilitators included positive role modeling, a strong sense of moral agency, and supportive peer environments.

Students largely perceive the deficit in moral courage as a systemic issue rather than an individual failure. Current educational models often prioritize compliance over advocacy, creating a perceived conflict between academic survival and ethical action for trainees. To foster active moral agents, medical education must reframe moral courage as a trainable "non-technical skill" and implement systemic reforms to dismantle the culture of silence in clinical environments.