Oil sands development in the lower Athabasca River watershed has raised considerable public and scientific concerns regarding perceived effects on environmental health. To address this issue for tributaries and the mainstem of the Athabasca River in the Athabasca Oil Sands Region, the Water Component of the Joint Oil Sands Monitoring (JOSM) plan produced monitoring assessments for seven integrated themes: atmospheric deposition, tributary water quality, river mainstem water quality, groundwater quality and quantity, water quality and quantity modelling, benthic invertebrate condition, and fish health. Our review integrates and synthesizes the large and diverse datasets assembled in the seven JOSM theme assessments to (i) evaluate possible environmental effects based on known sources and candidate proximal causes and (ii) determine the importance of cause-and-effect pathways related to contaminant, sediment, and nutrient inputs. Although JOSM research identified ecological effects that appear to be associated with contaminant exposure, the source of this exposure is confounded by co-location of, and inability to differentiate between, oil sands operations (principally released by atmospheric emission) and inputs from the natural bitumen outcrops (e.g., erosional material transported by surface and groundwater flows). Nutrient enrichment from treated municipal sewage effluent was the dominant ecological effect observed for the mainstem Athabasca River, associated with increased fish size and changes in invertebrate assemblages, likely because this pollution source is discharged directly into the river. If the direct release of treated oil sands process water occurs in the future, then the potential ecological impact of these direct industry releases will need to be evaluated carefully. The ecological causal assessment method proved to be a useful tool for better understanding how stressor sources relate to ecological effects through candidate proximate causes. Factors that confound our ability to assess the ecological effects of oil sands development focus on our inability to adequately differentiate between contaminants supplied from natural and anthropogenic contaminant sources. Our causal synthesis identifies options for changes in future monitoring to better anticipate and detect degradation in the ecosystem health of the lower Athabasca River and its tributaries.