Compounds related to foam properties in sparkling wines.
\r\n\t
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Since he graduated he has published several peer-reviewed papers at the national and international levels and he has been a guest researcher and lecturer both at Michigan State University (USA) and at the University of Toronto (Canada) where he has developed part of his Ph.D. research with the Financial support from the Portuguese Foundation for Science and Technology (Ph.D. grant).",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"108118",title:"Dr.",name:"Luis",middleName:null,surname:"Loures",slug:"luis-loures",fullName:"Luis Loures",profilePictureURL:"https://mts.intechopen.com/storage/users/108118/images/system/108118.png",biography:"Luís Loures is a Landscape Architect and Agronomic Engineer, Vice-President of the Polytechnic Institute of Portalegre, who holds a Ph.D. in Planning and a Post-Doc in Agronomy. 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According to the report published in the year 2014 by the International Organization of Vine and Wine [1], sparkling wine production increased by 40% in the last decade and by 7% compared to global wine production.
Sparkling wines are obtained after a second fermentation of a base wine that can be carried out in closed bottles or in hermetically sealed tanks. High quality sparkling wines, such as Champagne wines in France, Cava wines in Spain or Talento in Italy, are fermented in closed bottles following the traditional method, and they remain in contact with the yeast lees in a bottle. The first fermentation transforms grape must into base wine. The essence of the traditional method is the second fermentation, which takes place in the bottle and increases the alcohol content and internal bottle pressure (up to 5–7 atmospheres). After this second alcoholic fermentation, the wine is aged on yeast lees for at least 9 months (EC Regulation N° 606/2009) [2]. Autolysis of the yeast occurs during this prolonged contact and involves hydrolytic enzymes that act to release cytoplasmic (peptides, fatty acids, nucleotides, amino acids) and cell wall (mannoproteins) compounds into the wine. This aging on yeast lees leads to significant changes in wine composition and the organoleptic and foam properties of the wine are modified [3].
In sparkling wines the level of dissolved carbon dioxide (CO2) found in the liquid phase is indeed a parameter of paramount importance. CO2 is responsible for the visually appealing, and very much sought-after repetitive bubbling process (the so-called effervescence). In fact, foam is the characteristic that differentiates sparkling wines from still wines, being the first sensory attribute that tasters and consumers perceive and that determines the final quality of sparkling wines [4]. Moreover, dissolved CO2 is also responsible for the very characteristic tingling sensation in aroma and mouthfeel sensations [5]. During carbonated beverage tasting, dissolved CO2 acts on both trigeminal receptors [6], and gustatory receptors, via the conversion of dissolved CO2 to carbonic acid [7], in addition to the tactile stimulation of mechanoreceptors in the oral cavity (through bursting bubbles). Moreover, a link has been evidenced between carbonation and the release of some aroma compounds in carbonated waters [8].
The formation of foam, its stability and the size of the bubbles in sparkling wines are directly related to the surface tension. This can be defined as the force per unit area that maintains the bond between the molecules at the surface of the liquid. The presence of surfactants reduces the surface tension of the liquid and allows to the formation and persistence of bubbles. Secondary fermentation in sparkling wines leads to the formation of carbon dioxide, which increases the pressure inside the bottle and causes the gas to dissolve in the liquid. When the bottle is opened, the difference between the pressure in the bottle and that of the atmosphere causes the dissolved gas to spontaneously leave the liquid. Once the pressure on the surface of the liquid has been equalized with the atmospheric pressure, bubbles continue to form inside the liquid [9].
Currently, the quality of sparkling wine is linked to the formation and persistence of foam. Quality foam can be defined as one that causes a slow release of CO2, in ring shapes from the depths of the liquid, with small bubbles that contribute to the formation of a crown over the surface of the wine, covering it completely, and with bubbles two or three rows deep [10]. Foam duration is directly related to bubble stability, and stability is itself dependent on the composition of the film that supports it [11]. In sparkling wines, bubbles consist of gas surrounded by a film of wine constituents. These tensioactive components and other substances afford viscosity to the film, giving texture to the bubble (Figure 1) [4]. In fact, it was established that foaming properties depend on compounds that decrease surface tension and increase the viscosity of the film between the bubbles. This factor contributes to foam stabilization and renders the bubbles more resistant to coalescence [12, 13].
Carbon dioxide/liquid interphase of the bubble’s film. Adapted from Ref. [11].
In brief, foam formation and persistence is directly dependent upon its chemical composition, and the synergistic interaction among numerous foam active compounds which, due to aggregation or complex formation, may modify their surface-active properties. For this reason, and in order to ascertain which compounds affect foam quality, it is necessary to evaluate as many compounds as possible. In this sense, several scientific studies have been carried out in an attempt to determine the wine compounds that could play a role in the foam properties of sparkling wines. Many of these studies carried out in model solutions and in base and sparkling wines, are summarized in the reviews made by several authors [11, 14]. The present chapter increases the knowledge on this topic and reviews the latest studies made to determine the influence of proteins, peptides, amino acids, polysaccharides, phenolic compounds, lipids, organic acids and others on the foamability and foam stability of sparkling wines.
Most of the studies published in the literature on sparkling wine foam quality are aimed at establishing the effect of the chemical composition of grape juices, base wines and sparkling wines on their foaming properties. In order to correlate the foaming properties with the physical and chemical characteristics of sparkling wines, much effort has been made to find instrumental techniques that can be used to obtain a quantifiable value for foam quality, and consequently to be able to compare sparkling wines. Among them, methods based on measuring the kinetics of CO2 discharging, gas sparging methods, and image analysis methods are some of the most often employed [15].
An automated equipment, called “Mosalux” was designed to measure the foaming properties of wines [16]. This apparatus was adapted from that described by Rudin [17] and allows measurement of the increase with time of the height of a wine foam column submitted to a definite effervescence [16]. In fact, this is an objective and normalized method based on the interruption of a beam of ultra red light by the foam produced after the injection of CO2 into the wine. Three parameters can be measured.
HM: maximum height reached by the foam after carbon dioxide injection through the glass frit, expressed in mm; this could represent the foam-ability, the wine’s ability to foam.
HS: foam stability height during carbon dioxide injection, expressed in mm; this could represent the foam stability, the wine’s ability to produce stable foam or persistence of foam collar.
TS: foam stability time, until all bubbles collapse, when CO2 injection is interrupted, expressed in s; this could represent the foam stability time, once effervescence has decreased.
Figure 2 shows the description of the “Mosalux” equipment and an example of the plot generated during a foam measurement.
(a) Diagram of the “Mosalux” equipment. (1) Flowmeter, (2) test tube, (3) wine, (4) foam, (5) infrared emitter, (6) infrared receiver, (7) personal computer, (8) printer; (b) example of a foam profile of a sparkling wine.
The “Mosalux” equipment has been the most widely used since 1990 and in addition to research laboratories. It is probably the most used instrumental system in sparkling wine cellars for foam characterization. Moreover, a good relationship has been established between the foaming properties obtained by using “Mosalux” and foam sensory analysis [18]. The “Mosalux” apparatus has also been used to determine other parameters such as the expansion of foam E, the Bickerman coefficient Σ [19] (lifetime of a bubble in dynamic conditions, when formation and destruction of bubbles are balanced), and the lifetime of foam LF [20]. When comparing the different foam parameters (HM, HS, TS, E, LF, and ∑) obtained by the gas sparging method, it was concluded that the best parameters to characterize the foam capacities of wines were HM, ∑, and TS [21]. Other variation of this system uses an ultrasound emitter-detector and a waveguide to detect foam fluctuations [22, 23] to obtain Hpeak (maximum height reached by the foam after air injection through a glass frit). Hpeak has been related to the wine’s ability for foaming and Hplato (foam height stability during air injection) has been related to the average bubble lifetime. Correlation between the results obtained with this technique and sensory analysis has also been established [24].
Table 1 includes a summary of the compounds that have been related to foam properties in the different scientific studies published, making reference to the type of sample used: model wine, grape juice, base wine, sparkling wine or isolated foam.
Compounds | Type of sample | Results | References |
---|---|---|---|
Proteins | Model wine | Increase foam | [67] |
Model wine | Increase foam height | [38] | |
BWa | Increase foam height | [16] | |
Separated foam | Increase foam | [34, 35] | |
Model wine and BWa | Increase foam stability | [20] | |
BWa | Increase foam height and foam stability | [39] | |
BWa and SWa | Reduce foam height and increase foam stability | [29] | |
BWa | Increase foam height and reduce foam stability | [25] | |
SWa | Increase foam height and foam stability | [40] | |
Grape juice | Increase foam height | [12] | |
BWa | Increase foam height and reduce foam stability | [26] | |
SWa | Increase foam height, foam stability height and decrease foam stability time | [41] | |
Grape juice and BWa | Increase foam height | [42] | |
BWa and SWa | Increase foam height and foam height stability | [22] | |
BWa and SWa | Increase foam height | [43] | |
SWa | Increase foam height | [44] | |
BWa | Increase foam height | [45] | |
SWa | Increase foam height stability | [24] | |
BWa | Increase foam height and foam stability | [46] | |
SWa | Increase maximum height, foam height stability and effervescence | [23] | |
BWa | Increase foam stability | [70] | |
BWa and SWa | Increase foam height and foam stability height | [47] | |
SWa | Increase foam height and foam stability height | [48] | |
BWa and SWa | Increase foam height and foam stability height | [27] | |
Model wine | Cooperative effects between mannoproteins and the proteins of grape origin to improve foamability | [33] | |
BWa and SWa | Increase foam height | [49] | |
BWa | Increase foam height | [50] | |
Peptides | BWa and SWa | No influence on foam height and foam height stability | [22] |
SWa | Improve foam height stability | [24] | |
Amino acids | BWa | Decrease foam stability time | [25] |
SWa | Proline and glutamine increase foam height and foam stability height Decrease foam stability time | [41] | |
BWa and SWa | Increase foam height and foam height stability | [22] | |
SWa | Increase maximum height, foam height stability and effervescence | [23] | |
SWa | Increase foam height and foam stability height | [28] | |
Polysaccharides | Model wine | Increase foam stability | [38] |
Separated foam | Increase foam | [34] | |
BWa and SWa | Xylose in polysaccharides increase foam stability | [29] | |
BWa | Increase foam height | [25] | |
SWa | Increase foam height and stability time | [40] | |
BWa | Total polysaccharides increase foam height and reduce foam stability time Acid and neutral polysaccharides increase foam height | [26] | |
Grape juice and BWa | Total and neutral polysaccharides increase foam height | [42] | |
BWa and SWa | Increase foam height and foam height stability | [22] | |
BWa and SWa | Polysaccharides (Mr of 62,000–48,000, 13,000–11,000, and 3000 to 2000) increase foam height, and the Mr. 3000–2000 polysaccharide reduce foam stability | [43] | |
SWa | Total and acid polysaccharides decrease foam stability time | [66] | |
BWa | Reduce foam height | [45] | |
SWa | Mannoproteins increase maximum height, foam height stability and effervescence | [23] | |
Model wine and SWa | Increase foam height and foam height stability | [30] | |
Model wine | Increase foam stability | [56] | |
Model wine | Mannoproteins with low content of protein (5%) increase foam stability. Arabinogalactans and hydrophobic low molecular weight fraction (<1 kDa) increase foamability. | [32] | |
SWa | Mannoproteins, arabinogalactans and pectic polysaccharides (HMW) increase foam height, foam stability height and foam stability time | [31] | |
Model wine | Mannoproteins increase foamability | [33] | |
SWa | Mannoproteins and PRAG increase foam stability time | [28] | |
BWa and SWa | High molecular weight polysaccharides decrease foam height | [49] | |
BWa | Increase foam stability time | [50] | |
Polyphenols | Model wine | (+)-catechin increase foamability and foam stability | [61] |
SWa | Increase foam height and reduce foam stability | [40] | |
Grape juice | Total polyphenol increase foam height Nonflavonoid phenol increase foam height Flavonoid phenol increase foam height | [12] | |
BWa | Non flavonoids phenols decrease foam stability time | [26] | |
Grape juice and BWa | Total polyphenols, ortodiphenols, flavonoids and nonflavonoids reduce foam stability time | [42] | |
BWa | Reduce foam height | [45] | |
SWa | Anthocyanins increase foam height and foam stability height Proanthocyanidins decrease foam height and foam stability height | [28] | |
BWa | Increase foam stability time | [50] | |
Lipids | BWa | C8 and C10 increase collar height and reduce stability foam | [16] |
Model wine and BWa | Lipids are only foam active compounds at low alcohol concentration | [64] | |
BWa and SWa | Linoleic acid increase foam stability Palmitic acid increase foam height | [29] | |
BWa and separated foam | C8, C10, and C12 reduce foam height. Ethyl esters of hexanoic, octanoic, and decanoic acids increase foam height. | [65] | |
SWa | Monoacylglycerols of palmitic and stearic acids and glycerylethylene glycol fatty acid derivatives increase the promotion and stabilization of foam | [31] | |
Organic acids | Model wine and BWa | Tartaric acid increase foam | [20] |
BWa and SWa | Tartaric acid increase foam height | [29] | |
BWa | Malic acid increase foam height Titratable acidity increase foam height Lactic acid decrease foam height Citric and galacturonic acid reduce foam stability time pH reduce foam stability time | [25] | |
SWa | Malic acid increase foam height and reduce stability foam | ||
Grape juice | pH increase foam height Total acidity decrease foam height | [40] | |
SWa | Galacturonic acid decrease foam stability time | [12] | |
BWa | Titratable acidity, malic acid increase foam height and reduce foam stability time Lactic acid reduce foam height and increase foam stability time Citric acid and galacturonic acid reduce foam stability time | [41] | |
BWa | Malic acid increase foam height | [26] | |
SWa | Tartaric acid increase foam height pH decrease foam height Lactic acid decrease foam stability time | [45] | |
BWa and SWa | Gluconic acid reduce foam height | [49] | |
Others | Separated foam | Iron increase foam | [34] |
Model wine and BWa | Glycerol increase foam | [20] | |
BWa and SWa | Glucose increase foam height Total content of SO2 reduce foam stability ɤ-butyrolactone increase foam stability | [29] | |
BWa | Acetaldehyde, ethyl acetate, diacetaldehyde and isoamylic alcohols reduce foam stability time Alcohol content increase foam height and foam stability height Glucose increase foam height and fructose reduce foam height | [25] | |
Grape juice | Fructose, glucose and methanol increase foam height Free sulfur dioxide decrease foam height Soluble solid concentration and maturity index increase foam height | [12] | |
BWa | Alcohol content increase foam height Turbidity increase foam height and reduce foam stability time Free sulfur dioxide increase foam height and reduce foam stability time Conductivity increase foam height and reduce foam stability time | [26] | |
SWa | Residual sugars and ethanolamine increase foam height and foam stability height Ethyl acetate decrease foam stability time | [41] | |
SWa | Botrytis cinerea infection decrease foamability | [44] | |
BWa | Alcohol concentration and total SO2 reduce foam height | [45] | |
SWa | Ethanol, volatile acidity and total SO2 reduce foam height Volatile acidity and total SO2 reduce foam stability time | [66] | |
BWa | Lysozyme have a protective effect on foaming properties | [71] | |
Model wine | Botrytis cinerea protease activity decrease wine foaming properties | [69] | |
BWa | Botrytis cinerea infection decrease foamability and foam stability | [70] | |
Model wine | Glycerol and glycerol plus ethyloctanoate increase foam height and foam stability time | [32] | |
BWa and SWa | Ethanol content reduce foam height | [49] |
Compounds related to foam properties in sparkling wines.
BW: base wines; SW: sparkling wines.
Table 2 shows the correlations (r) at significance level (p < 0.05) between parameters that determine foam properties (HM, HS, TS, Peak H and Plateau H) and the chemical composition of grape juices, base wines and sparkling wines.
Compounds | Type of sample | HM | HS | TS | Peak H | Plateau H | References |
---|---|---|---|---|---|---|---|
Proteins | BWa | 0.32 | −0.51 | [25] | |||
Grape juice | 0.91 | [12] | |||||
SWa | 0.62 | 0.49 | [22] | ||||
BWa | 0.31 | [45] | |||||
BWa and SWa | 0.58 | [49] | |||||
BWa and SWa | 0.44 | [43] | |||||
Grape juice | 0.75 | [42] | |||||
Amino acids | |||||||
Total amino acids | SWa | 0.85 | 0.63 | [28] | |||
Acid amino acids | SWa | 0.82 | 0.58 | [28] | |||
Neutral amino acids | SWa | 0.85 | 0.68 | [28] | |||
Basic amino acids | SWa | 0.75 | 0.62 | [28] | |||
Total biogenic amines | SWa | 0.66 | 0.64 | 0.48 | [28] | ||
Aspartic acid | SWa | 0.52 | 0.67 | [22] | |||
SWa | 0.86 | 0.63 | [28] | ||||
Hydroxyproline | BWa | −0.39 | [25] | ||||
SWa | 0.46 | [28] | |||||
Glutamic acid | BWa | −0.50 | [25] | ||||
SWa | 0.66 | 0.71 | [22] | ||||
SWa | 0.77 | 0.54 | 0.46 | [28] | |||
Serine | BWa | −0.425 | [25] | ||||
SWa | 0.56 | 0.68 | [22] | ||||
SWa | 0.62 | 0.59 | 0.58 | [28] | |||
Asparagine | BWa | −0.38 | [25] | ||||
SWa | 0.41 | 0.57 | [22] | ||||
SWa | 0.79 | 0.68 | 0.45 | [28] | |||
Glycine | BWa | −0.39 | [25] | ||||
SWa | 0.41 | 0.57 | [22] | ||||
SWa | 0.88 | 0.66 | 0.35 | [28] | |||
Glutamine | BWa | 0.37 | −0.36 | [25] | |||
SWa | 0.53 | [22] | |||||
SWa | 0.42 | [28] | |||||
Histidine | SWa | 0.50 | 0.48 | [22] | |||
Threonine | SWa | 0.56 | 0.42 | [28] | |||
Proline | BWa | 0.34 | 0.58 | 0.69 | [25] | ||
SWa | [22] | ||||||
SWa | 0.82 | 0.60 | 0.34 | [28] | |||
Histamine | SWa | 0.39 | 0.42 | 0.43 | [28] | ||
GABA | BWa | −0.38 | [25] | ||||
SWa | 0.52 | 0.60 | [22] | ||||
SWa | 0.77 | 0.52 | [28] | ||||
Arginine | BWa | −0.36 | [25] | ||||
SWa | 0.50 | 0.62 | [22] | ||||
SWa | 0.83 | 0.65 | [28] | ||||
α alanine | SWa | 0.53 | 0.63 | [22] | |||
BWa | −0.37 | [25] | |||||
SWa | 0.83 | 0.65 | 0.39 | [28] | |||
Β alanine | SWa | 0.92 | 0.55 | [28] | |||
Tyrosine | BWa | −0.53 | [25] | ||||
SWa | 0.49 | 0.63 | [22] | ||||
SWa | 0.81 | 0.60 | [28] | ||||
Valine | BWa | −0.50 | [25] | ||||
SWa | 0.52 | 0.67 | [22] | ||||
Methionine | BWa | −0.34 | [25] | ||||
SWa | 0.51 | 0.63 | [22] | ||||
SWa | 0.89 | 0.58 | [28] | ||||
Cysteine | SWa | 0.79 | 0.49 | [28] | |||
Isoleucine | BWa | [25] | |||||
SWa | 0.67 | 0.64 | 0.47 | [28] | |||
Leucine | BWa | −0.34 | [25] | ||||
SWa | 0.51 | 0.64 | [22] | ||||
SWa | 0.42 | 0.55 | 0.55 | [28] | |||
Phenylalanine | BWa | −0.29 | [25] | ||||
SWa | 0.42 | 0.62 | [22] | ||||
SWa | 0.84 | 0.62 | 0.36 | [28] | |||
Ornithine | BWa | −0.31 | [25] | ||||
SWa | 0.79 | 0.64 | [28] | ||||
Tryptophan | BWa | −0.37 | [25] | ||||
SWa | 0.85 | 0.59 | [28] | ||||
Lysine | BWa | −0.36 | [25] | ||||
SWa | 0.52 | [22] | |||||
SWa | 0.66 | 0.61 | [28] | ||||
Spermidine | SWa | 0.72 | 0.41 | [28] | |||
Tyramine | SWa | 0.35 | [28] | ||||
Putrescine | SWa | 0.51 | 0.59 | 0.43 | [28] | ||
Cadaverine | SWa | −0.35 | [28] | ||||
Phenylethylamine | SWa | 0.60 | [28] | ||||
Isoamylamine | SWa | −0.55 | [28] | ||||
Polysaccharides | |||||||
Total polysaccharides | Grape juice | 0.55 | [42] | ||||
BWa | 0.40 | [42] | |||||
SWa | 0.80 | 0.68 | [22] | ||||
SWa | 0.64 | [28] | |||||
Polysaccharides from yeasts | SWa | 0.53 | [28] | ||||
Polysaccharides from grapes | SWa | 0.68 | [28] | ||||
Neutral polysaccharides | Grape juice | 0.65 | [42] | ||||
BWa | 0.46 | [42] | |||||
SWa | 0.82 | 0.71 | [22] | ||||
Acid polysaccharides | BWa | −0.76 | [45] | ||||
High molecular weight polysaccharides | BWa and SWa | −0.65 | [49] | ||||
Polysaccharides Molecular Mass 62,000–48,000 | BWa and SWa | 0.51 | [43] | ||||
Polysaccharides Molecular Mass 13,000–11,000 | BWa and SWa | 0.46 | [43] | ||||
Polysaccharides Molecular Mass 3000–2000 | BWa and SWa | 0.32 | [43] | ||||
Mannoproteins | SWa | 0.47 | [28] | ||||
Polysaccharides rich in arabinose and galactose | SWa | 0.72 | [28] | ||||
Homogalacturonans | SWa | 0.58 | [28] | ||||
Glucans | SWa | 0.40 | [28] | ||||
Polyphenols | |||||||
Absorbance 520 (nm) | BWa | −0.35 | [25] | ||||
Absorbance 280 (nm) | Grape juice | 0.92 | [12] | ||||
BWa | −0.63 | [42] | |||||
Total polyphenol | Grape juice | 0.76 | [12] | ||||
BWa | −0.60 | [42] | |||||
BWa | −0.45 | [45] | |||||
Total proanthocyanidins | SWa | −0.73 | [28] | ||||
Nonflavonoid phenol | Grape juice | 0.59 | [12] | ||||
BWa | −0.33 | [42] | |||||
Total flavan-3-ols | SWa | 0.50 | 0.42 | [28] | |||
Flavonoid phenol | Grape juice | 0.52 | [12] | ||||
BWa | −0.64 | [42] | |||||
Ortodiphenols | BWa | −0.49 | [42] | ||||
Total monomeric anthocyanins | SWa | 0.96 | 0.80 | [28] | |||
Non-acylated anthocyanins | SWa | 0.97 | 0.81 | [28] | |||
Acetyl-glucoside anthocyanins | SWa | 0.94 | 0.75 | [28] | |||
Coumaryl-glucoside anthocyanins | SWa | 0.88 | 0.67 | [28] | |||
delphinidin-3-glucoside | SWa | 0.94 | 0.71 | [28] | |||
cyanidin-3-glucoside | SWa | 0.84 | 0.60 | [28] | |||
petunidin-3-glucoside | SWa | 0.95 | 0.73 | [28] | |||
peonidin-3-glucoside | SWa | 0.87 | 0.65 | [28] | |||
malvidin-3-glucoside | SWa | 0.98 | 0.85 | [28] | |||
delphinidin-3-(6-acetyl)-glucoside | SWa | 0.91 | 0.67 | [28] | |||
cyanidin-3-(6-acetyl)-glucoside | SWa | 0.89 | 0.62 | [28] | |||
petunidin-3-(6-acetyl)-glucoside | SWa | 0.92 | 0.69 | [28] | |||
peonidin-3-(6-acetyl)-glucoside | SWa | 0.89 | 0.65 | [28] | |||
malvidin-3-(6-acetyl)-glucoside | SWa | 0.89 | 0.92 | [28] | |||
delphinidin-3-(6-p-coumaryl)-glucoside | SWa | 0.76 | 0.52 | [28] | |||
cyanidin-3-(6-p-coumaryl)-glucoside | SWa | 0.92 | 0.68 | [28] | |||
petunidin-3-(6-p-coumaryl)-glucoside | SWa | 0.78 | 0.55 | [28] | |||
peonidin-3-(6-p-coumaryl)-glucoside | SWa | 0.91 | 0.67 | [28] | |||
malvidin-3-(6-p-coumaryl)-glucoside | SWa | 0.94 | 0.76 | [28] | |||
cis-caftaric | SWa | −0.65 | [28] | ||||
trans-fertaric | SWa | 0.35 | [28] | ||||
coumaric acid | SWa | 0.77 | 0.37 | [28] | |||
ferulic acid | SWa | −0.39 | −0.41 | [28] | |||
gallic acid | SWa | 0.62 | [28] | ||||
(+)-catechin | SWa | 0.50 | 0.42 | [28] | |||
quercetin-3-rutinoside | SWa | −0.43 | [28] | ||||
myricetin | SWa | 0.36 | [28] | ||||
quercetin | SWa | 0.58 | [28] | ||||
kaempferol | SWa | 0.53 | [28] | ||||
isorhamnetin | SWa | 0.84 | [28] | ||||
Lipids | |||||||
C8 (n = 28) | BWa and separated foam | −0.43 | [65] | ||||
C10 (n = 28) | BWa and separated foam | −0.66 | [65] | ||||
C12 (n = 28) | BWa and separated foam | −0.57 | [65] | ||||
Ethyl hexanoate (n) 28 | BWa and separated foam | 0.65 | [65] | ||||
Ethyl octanoate (n) 28 | BWa and separated foam | 0.86 | [65] | ||||
Ethyl decanoate (n) 28 | BWa and separated foam | 0.90 | [65] | ||||
Organic acids | |||||||
Titratable acidity | BWa | 0.46 | [25] | ||||
Grape juice | −0.59 | [12] | |||||
pH | BWa | −0.32 | [25] | ||||
Grape juice | 0.71 | [12] | |||||
Citric acid | BWa | −0.38 | [25] | ||||
Galacturonic acid | BWa | −0.42 | [25] | ||||
Malic acid | BWa | 0.46 | [25] | ||||
BWa | 0.40 | [45] | |||||
Lactic acid | BWa | −0.43 | [25] | ||||
Gluconic acid | BWa and SWa | −0.36 | [49] | ||||
Others | |||||||
Alcohol content | BWa | 0.47 | 0.46 | [25] | |||
BWa | −0.47 | [45] | |||||
BWa and SWa | −0.92 | [49] | |||||
Glucose | BWa | −0.31 | [25] | ||||
Grape juice | 0.58 | [12] | |||||
Fructose | BWa | 0.56 | 0.32 | [25] | |||
Grape juice | 0.73 | [12] | |||||
Ethanolamine | BWa | 0.31 | [25] | ||||
Acetaldehide | BWa | −0.35 | [25] | ||||
Ethyl acetate | BWa | −0.51 | [25] | ||||
Diacetaldehyde | BWa | −0.36 | [25] | ||||
Isoamylic alcohols | BWa | −0.43 | [25] | ||||
Maturity index | Grape juice | 0.78 | [12] | ||||
Soluble solid concentration | Grape juice | 0.75 | [12] | ||||
Methanol | Grape juice | 0.80 | [12] | ||||
Free sulfur dioxide | Grape juice | −0.65 | [12] | ||||
Total sulfur dioxide | BWa | −0.68 | [45] |
Correlation coefficients (r) at significance levels (p < 0.05) between parameters that determine foam properties (HM, HS, TS, Peak H and Plateau H) and the chemical composition of grape juices, base wines and sparkling wines.
BW: base wines; SW: sparkling wines.
In the majority of the works shown in Tables 1 and 2, the chemical compounds have been related to the foam physical parameters obtained by the “Mosalux” device [12, 16, 25, 26, 27, 28] or other variations of this method [20, 22, 23, 24, 29, 30, 31, 32, 33]. All studies have shown that the foam properties of sparkling wines mainly depend on the qualitative composition and quantitative content of surface active substances. The relation found between the foaming properties and the different wine macromolecules is detailed below.
Despite of the low concentration of proteins in sparkling wines (ranging from 4 to 16 mg/L) [14], previous works have shown that these compounds are largely involved in the foaming properties of sparkling wines due to their surfactant properties. Surfactant agents are inferred to stabilize foams by settling at the bubble’s edge, with the hydrophobic side interacting with the gas phase and the hydrophilic side interacting with the aqueous liquid phase [34]. The behavior of proteins in the foam depends on their hydrophobicity, solubility (dependent on the isoelectric point and the pH of the wine), and molecular weight [35, 36]. The net charge of macromolecules depends on the pH [37]. The isoelectric point of the wine proteins is between 3.5 and 4.5 [35] and between 4.6 and 5.0 [29]. At the wine pH, 2.9, its proteins would be positively charged and could migrate to the wine/air interphase and to stabilize foam [20]. However, characterization of foaming proteins have showed that foam formation is dependent on protein hydrophobicity but not on their molecular weight or isoelectric point [34].
Proteins have been the most studied compounds in relation to wine foamability. Most studies indicate a positive influence of protein content on foam height in grape juices, base wines and sparkling wines [16, 20, 22, 23, 24, 25, 26, 27, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50] (Tables 1 and 2). Some of this studies showed positive correlations between proteins and parameter HM [12, 25, 42, 43, 45, 49], Peak H, and Plateau H [22]. The highest correlations between proteins and foamability parameters were observed in juices of white grapes (r > 0.75) [12, 42]. Correlation between proteins and foamability parameters was lower in base wines and sparkling wines [22, 25, 43, 45, 49] (Table 2). The work conducted in Spanish sparkling wines was an exception to this because authors observed a negative relation between proteins and foam height [29].
The correlations between proteins and foam stability have shown contradictory results. Therefore, some proteins have been described as good foam formers but poor stabilizers, while others are poor foam formers but good stabilizers [13, 20, 25, 26, 29, 39, 41]. Inverse relationship between HM and TS [16, 25, 26] could justify that proteins may be active agents on foamability but may not sustain a foam collar for a long time.
The influence of specific proteins on foam quality has also been studied in several research papers. Grape invertase is one of the most abundant protein present in wine (from 9 to 14% of the total protein content of a Chardonnay wine) [51]. This grape protein possesses a pI close to the pH of wine and a high hydrophobicity, potentially conferring good surface properties on this protein [51]. Significant decreases in the invertase content in base wines have been shown to correlate with decreases in foam height and foam stability [46]. Other grape proteins, such as thaumatin-like proteins and chinases, did not contribute alone to the formation and stabilization of foam; however, when synergistically acting with mannoproteins, foam height was found to be maximized [33]. On the other hand, the release of proteins from the yeast cells prior to autolysis has also been shown to contribute to foam height and foam stability height in sparkling wines [23, 24, 47].
The hydrophobicity of peptides may be related to the quality of sparkling wine foam [52, 53]. Proteins and peptides with molecular weight within 24–60 kDa, even in low concentrations, provide for the foam formation in base wine [13, 31, 47] since they form adsorption layers with high mechanical strength and, as a result, increase the stability of the sparkling wine foam. In fact, a positive correlation has been reported between polypeptide molecular mass, hydrophobicity and foam stabilizing activity in beer [54, 55]. Although no correlations have been found between peptides and foam properties of sparkling wines [22], bentonite added to the tirage solution produced a reduction in both protein and peptide contents and thereby negatively affected foaming properties [24] (Table 1).
In addition to proteins and peptides, some authors agree in considering amino acids as foaming agents. At wine pH, amino acids carry a net positive charge, so they are surfactant with hydrophilic and hydrophobic groups. This property causes amino acids to be retained in the air/liquid interface, and thus reduces the wine surface tension, improving the sparkling wine ability to foam [28].
Moreno-Arribas et al. [22] showed positive correlations between free amino acids and white sparkling wine foamability (Tables 1 and 2). The authors observed that maximum height (Peak H) was significantly correlated with most of the amino-acids, although coefficients of over 0.60 were only found for glutamic acid (r = 0.66). Moreover, Plateau H (associated to bubble lifetime) was highly correlated with glutamic acid (r = 0.71), serine (r = 0.68), valine (r = 0.67) and proline (r = 0.69). Lower positive correlations were found by Andrés-Lacueva et al. [25] in white base wines between glutamine and proline and foamability parameters.
Other study conducted by our research group in white and rosé sparkling wine showed the highest positive correlations between total amino acids and foam height (r = 0.85) and total amino acids and foam stability height (r = 0.63) [28] (Table 2). Biogenic amines showed the same behavior as amino acids, although lower correlation values were observed [28] (Table 2). When comparing the different amino acids analyzed, glycine, β-alanine, and methionine had the highest correlation with foam height (r > 0.88) [28] (Table 2). In general, amino acids with non-polar side chains showed higher values of correlation than amino acids with polar side chains. At wine pH, amino acids are protonated and they act as cationic surfactants according to the hydrophobicity of their side chains. Their amphiphilic character could cause amino acids to become concentrated at the liquid–gas interfaces, improving the sparkling wine foamability [28].
Negative correlations have been observed between amino acids and foam stability time in base wines [25] (Tables 1 and 2). However, conflicting results have been published on the influence of amino acid on foam stability of sparkling wines. It has shown that lower levels of amino acids favors a greater stability time of foam [41]; while other authors did not found any influence of these compounds on the foam stability time [28].
It was confirmed that the autolytic capacity of yeast was important for the quality of sparkling wines [23]. The use of a mutant having accelerated autolysis showed that the second fermentation of wines with this mutant improved the foaming properties versus a control strain due to higher increase in both nitrogen compounds (proteins, peptides and amino acids) and polysaccharides [23].
Contradictory results have been published on the effect of polysaccharides on foam quality. Girbau Sola et al. [45] showed a negative influence of acid polysaccharides on foam height in base wines (r = −076). The same authors showed that polysaccharides were negatively correlated with foam stability but positively with the average bubble lifetime or Bikerman’s coefficient [45]. Similarly, polysaccharides with a molecular weight higher than 180 kDa have also shown a negative influence on foam height (r = −0.65), although these authors associated the negative contribution with the presence of β-glucans secreted by Botrytis cinerea and stated that other polysaccharides probably would not have a negative effect [49] (Tables 1 and 2).
In contrast with the results described above, most studies point to a positive influence of total polysaccharides on both foamability [22, 25, 26, 40, 42] and foam stability [28, 29, 50, 56] (Table 1). The relation of the molecular weight of polysaccharides and the foaming properties of wines has also been studied. Polysaccharides of molecular mass of 62 to 48 kDa; 13 to 11 kDa; and 3 to 2 kDa have been demonstrated to be active agents on foamability, and polysaccharides with molecular mass of 3 to 2 kDa might be a foam stability agent, since they were correlated with the Bikerman coefficient [43].
Among polysaccharides, glycoproteins like mannoproteins released by yeast during fermentation and autolysis, have been described as the major compounds affecting foaming properties [13, 23, 30, 33]. The hydrophobic nature of glycoproteins explains why they are better foam stabilizers and foam producers than non-glycosylated proteins. Glycoproteins present a protein moiety with hydrophobic and hydrophilic domains and sugar moieties, which are hydrophilic and they could interact with surface-active materials and be absorbed at the gas/liquid interface. The hydrophilic glycans are located at the liquid layer, among the bubbles, corresponding to the oxidic zone of the protein. Hence, when the layer surrounding the bubbles becomes thinner, the viscosity increases and drainage of the liquid is delayed. The hydrophobic polypeptides increase the surface tension of the bubbles, resulting in more stable foam [13]. In this sense, the literature has tried to explain the influence of mannoproteins on foaming properties. Mannoproteins also influence the viscosity of the bubble wall and reduces the drainage of the liquid [34]. Foaming may be due to their interactions with proteins [36] and their surface properties and capacity to reorientation quickly at the liquid/gas interface in the bubble when the foam is formed [20]. In fact, the proteinaceous fraction of mannoproteins is able to bind to the liquid/air interface and interact with other compounds by means of electrostatic or hydrophobic forces, hydrogen bonds, or covalent linkages [13]. These interactions could lead to the formation of a strong viscoelastic film that could be highly resistant to tension and able to withstand the film’s thickness [13], preventing coalescence of bubbles and leading to more stable foams. As a matter of fact the presence of both glycocompounds and protein material deriving from macromolecular fractions of different molecular weights in the adsorption layer of the foam of sparkling wines has been reported [56], and the presence of aggregated materials involving yeast glycoproteins and other unidentified wine components has also been indicated as contributing to the foam stability of sparkling wines [57, 58]. In this sense, reconstitution experiments performed by adding in a model solution different molecular fractions isolated from wine indicated that a synergistic effect in foamability and foam stability exists between high and low molecular weight wine compounds [31]. The fraction most responsible for foam stability was mainly influenced by mannoproteins with low content of protein (5%) and the foamability by arabinogalactans and a hydrophobic low molecular weight fraction (< 1 kDa) [32].
The specific contribution of the different families of wine polysaccharides to the wine foaming properties has been recently studied by our research group [28]. Mannoproteins, glucans, polysaccharides rich in arabinose and galactose, rhamnogalacturonans type II, and homogalacturonans did not show any influence on the foamability of sparkling wines. On the contrary, positive influence was found between foam stability time and all wine polysaccharides, with the exception of rhamnogalacturonans type II. Surprisingly, polysaccharides rich in arabinose and galactose showed higher positive correlations on foam stability (r = 0.72) than mannoproteins (r = 0.47) [28] (Table 2).
It is widely known that polyphenols are highly reactive compounds. Some authors have tried to establish a correlation between them and the quality of foam in grape juices, base wines and sparkling wines. Polyphenols can interact with proteins and polysaccharides [36, 37], mainly the low molecular weight polyphenols [59], which participate in the hydration layer of the proteins [60]. Moreover, the formation of hydrogen bonds between the hydroxyl groups of the phenolic compounds and the polar head groups of proteins can be particularly relevant for the interaction with the air/liquid interface of the bubble film [61, 62]. These formed compounds could adsorb at the interface and form a stabilizing film around bubbles, which could promote foam formation [28].
Most of the studies carried out to correlate the influence of phenols on foam quality of sparkling wines have shown contradictory results [12, 26, 28, 40, 42, 45, 50, 61] (Tables 1 and 2). In fact, total phenolics did not shown correlation with any foam instrumental property in sparkling wines [28], but they showed a negative correlation with foam height in base wines (r = −0.45) [45], and a high positive correlation with foam height in grape juices (r = 0.76) [12]. Moreover, most of studies refer to global measurements of phenolic compounds, which could lead to inaccurate results difficult to understand. A recent study of our group has analyzed the relation of individual phenolics with foam parameters in white and rosé sparkling wines, which could be critical for their production [28].
The study concluded that each phenolic compound exhibits different behavior patterns on foam instrumental properties (Table 2). Non acylated, acetyl glucoside and coumaryl glucoside anthocyanins showed the highest positive correlations with foamability, with values ranging from 0.67 to 0.97, but these compounds did not show any effect on the foam stability time. Authors attributed this effect to the interaction of anthocyanins with wine proteins through hydrophobic interactions and hydrogen bonds. Attachment of a long aliphatic chain could confer interesting surfactant behavior on flavylium cations. Therefore, the product formed could be retained in the liquid/air interface, resulting in a reduction of the interfacial tension and an increase in the foamability. On the other hand, total proanthocyanidins showed high negative correlation with sparkling wine ability to foam (r = −0.73). Since proteins play an important role on the foamability of sparkling wines, the negative correlation of proanthocyanidins with foam height could be due to the precipitation of wine proteins by tannins. Cis-caftaric was the hidroxicinamic acid most negatively correlated with foam height (r = −0.65), while coumaric acid showed the most positive effect (r = 0.77) and isorhamnetin was the flavonol with a major influence on foam height (r = 0.84).
Some authors describe that lipids can accumulate in the foam, reducing surface tension and stabilizing it [63]. However, the researches made in wines to establish the possible relationships among lipid content, fatty acids, and foam behavior have produced contradictory findings (Table 1). The addition of octanoic and decanoic fatty acids to wines had a negative effect on the foam stability time, but it positively influenced foam collar height [16]. However, the addition of a lipid mixture to wine did not affect their foam, but when the ethanol concentration was reduced, authors observed an adverse effect on bubble lifetime [64]. They concluded that linolenic acid and palmitic acid were, respectively, the best indicators of foam stability and foam height in base wines and sparkling wines respectively, both having a positive influence [29].
Moreover, it was studied the influence of fatty acids (free and bound as ethyl esters) on wine foaming in different white wines and separated foam (Tables 1 and 2). The free fatty acids C8, C10, and C12 were negatively correlated with foam height with values ranging from 0.43 to 0.66, whereas the ethyl esters of hexanoic, octanoic, and decanoic acids were positively related with values ranging from 0.65 to 0.90. These authors found that the value of foam height was directly proportional to the ratio of esterified to non-esterified fatty acids. So, the higher the coefficient, the greater the foamability; thus, it appeared that it was the esterified forms of fatty acids that increased foam height [65]. It was also shown that monoacylglycerols of palmitic and stearic acids and glycerylethylene glycol fatty acid derivatives were surface active compounds preferentially partitioned by the sparkling wine foam rather than the liquid phase, allowing the inference of their role as key components in the promotion and stabilization of sparkling wine foam [31].
With regards to organic acids (Tables 1 and 2), López-Barajas et al. [12] observed low negative correlations between titratable acidity and foamability in grape juices of white varieties (r = −0.58). However, other studies showed that tartaric acid, titratable acidity and pH increased foam height in grape juices, base and sparkling wines [12, 20, 25, 26, 29, 66]. In fact, pH and foamability in grape juices were highly correlated (r = 0.71) [12], while titratable acidity exhibited lower influence on foam height (r = 0.46) and foam stability time (r = −0.32) in white base wines [25]. In the same way, it was observed that acidity had a marked effect on foam since it modified protein solubility; if the juice acidity was low, protein hydrophobicity would be high, the surface activity could be increased, and then juice would have a higher foamability [35].
Different authors agree in pointing to malic acid as an enhancer of the foam height in base wines and sparkling wines [25, 26, 40, 45], but also stated that malic acid reduces foam stability time [26, 40]. On the contrary, lactic acid exerted the opposite effect on foam height [25, 26]. Malic acid and lactic acid showed low negative correlations with foam height [25, 45], which could indicate that malolactic fermentation is not recommended as a way to maximize foamability in sparkling wines. Moreover, conflicting results have been published on the influence of lactic acid on foam stability time. Some authors have observed a positive influence of lactic acid on foam stability in base wines [26], while others showed the opposite effect in sparkling wines [66]. Other acids such as citric and galacturonic acid reduced foam stability time in base and sparkling wines [25, 26, 41]. Moreover, the presence of gluconic acid due to Botrytis cinerea was shown to negatively affect wine foamability (r = −0.36) [49].
Several authors agree that sulfur dioxide negatively affect the foaming qualities of wines [12, 26, 29, 45, 66] due to SO2 is a denaturing agent of proteins [16]. In fact, negative correlations have been obtained between free and total sulfur dioxide and foam height in grape juices and base wines [12, 45].
There is some controversy about the effect of ethanol content on foaming quality. Some authors consider that ethanol has beneficial effects on foam [25, 26] while others assign it negative contribution [45, 49, 66]. The negative effect of ethanol on foam seems to be dependent on its content [67]. This could be explained by the ethanol modification of the solvent properties, the interactions between the protein and the solvent, and the structure of the adsorption layer [68]. When the alcohol content is low, other surfactants can be more active and thus more easily adsorbed at the interface, stabilizing the foam formed [20, 64]. In this sense, higher alcohol content was reported to decrease foamability [16]; however, this effect could be counteracted by other compounds produced in the second fermentation. In this regard, juices with a maturation index [ratio between soluble solids (°Brix) and titratable acidity (grams of tartaric acid per litter of juice) ranging from 4 to 5.5 had high foamability [12]. In fact, it was observed a high positive correlation between foam height and maturation index (r = 0.78) [12]. Subsequently, these results were confirmed, showing that maturation indexes for foamability and stability above 5.5 provided the wine with a less optimal alcoholic content for the formation of foam than wine produced from grapes with a maturation index within the stated range [45].
Glycerol is known to contribute to the viscosity of the wines. Due to its tensoactive properties, glycerol has shown a positive influence on foamability in sparkling wines [20, 32]. On the other hand, iron [34] and residual sugars [25, 29, 41] have been related with an improvement of foamability in sparkling wines.
The effect of Botrytis cinerea on the foaming characteristics of sparkling wines has also been studied [44, 69, 70]. In these works, it was concluded that this infection can cause a drastic reduction in foamability, since it uses up the proteins in the medium.
Diverse studies have been published about the influence of stabilization treatments, either using clarifiers or filtrations, on the foam quality of wines [20, 24, 41, 46, 47, 71, 72, 73, 74]. In all cases, the foams were negatively affected by these treatments, and this was directly correlated with a decrease in the protein concentration. On the contrary, lysozyme additions made to the musts and wines before and after bentonite or charcoal treatments seem to have a protective effect on the wine proteins, and thereby an increase in foamability [71].
Research conducted suggest that many compounds influence foam capacity of sparkling wines (Tables 1 and 2); however, the most influencing compounds on the foaming properties have proved to be total amino acids, polysaccharides, anthocyanins, coumaric acid and isorhamnetin, all of them showing correlation coefficients higher than 0.75 (Table 2). On the contrary, the alcohol content and the concentration of acid polysaccharides, proanthocyanidins and free SO2 are the factors which most negatively affect foam quality (Table 2).
In view of the results shown in Tables 1 and 2, it can be concluded that foamability and foam stability is a complicated issue. In fact, the foaming capacity of wines depends on a complex equilibrium among all the compounds that favor its formation and stability and those that do not. There is not one compound or group of compounds that is responsible for making and keeping good quality foam. Instead, foam quality depends on a synergistic relationship between many different compounds that when acting together result in the foaming properties.
Foam behavior results from the synergistic interaction between the different foam active compounds which, due to aggregation or complex formation, may modify their surface-active properties. Thus, foaming properties not only are due to the presence or absence of a specific group of compounds but also are influenced by the net balance of the number and type of compounds ranging among different chemical structures. For this reason, and in order to ascertain which compounds have a major influence on the foam quality of sparkling wines, it is necessary to evaluate as many compounds together as possible, and to study the combined effect of all them. In this sense, statistical tools of multiple linear regression [12, 22, 26, 28, 75] and partial least squares regression analysis [29] has been used by several authors in an attempt to predict the foam properties of sparkling wines, and find out the chemical compound that provided the best predictive model of the foam properties.
Most of the studies include in the models all the variables that are usually analyzed in the wineries, and try to predict values for foamability, foam stability and Bickerman coefficient Σ [12, 26, 75]. Results of these researches have shown a great influence of proteins, SO2, absorbance at 280 nm, glycerol and maturation index. Moreover, stepwise analysis showed that the foam height and Bickerman coefficient of sulphited grape juices could be predicted with a probability higher than 89.97% by the following polynomial equations (Eq. (1) and (2)) [12]:
Other study conducted by Pueyo et al. [29] applied PLS regression to predict foam height and foam stability in base wines and sparkling wines using 73 chemical variables analyzed. Tartaric acid, glucose, total palmitoleic acid and protein content were the most influent variables in the prediction of foam height in base wines. However, total contents of oleic, palmitic, and stearic acids, and the content of 1-hexanol were the most important variables for predicting foam height in sparkling wines. With regards to foam stability, the variables with high predictive relevance in base wines were the total content of linolenic and undecanoic acids and the free content of undecanoic acid, while the total content of SO2, the isobutanol, the total acidity, and proteins were the variables with high predictive relevance.
Moreno-Arribas et al. [22] observed that neutral polysaccharides, protein nitrogen and phenylalanine displayed high positive contribution to the prediction of maximum foam height (Peak H), and height at which the foam stabilizes in sparkling wines (Plateau H). The fitted final models, which presented the following adjusted equations (Eq. (3) and (4)), explained 76% of Peak H variation and 70% of the variation of Plateau H.
A recent work carried out in our group in 2015 used multiple linear regression analysis in white and rosé sparkling wines differentiating models which anthocyanins were included. It was concluded that the different forms of malvidin had the highest influence on the foam height and foam stability height parameters, followed by amino acid compounds ((Eq. (5) to (8)), while foam stability model was only predicted by polysaccharides from grapes, concretely by polysaccharides rich in arabinose and galactose ((Eq. (9) and (10)) [28].
In conclusion, this work shows that the foam properties of sparkling wines are ruled by a large number of molecules that act in a synergistic way. Nevertheless, some compounds seem to be more relevant than others to explain their foam properties.
Although contradictory results have sometimes been obtained, a high correlation (≥ 0.75) has been found in the literature between the foam properties of sparkling wines and the content of total amino acids, polysaccharides, anthocyanins, coumaric acid and isorhamnetin. On the contrary, the alcohol content and the concentration of acid polysaccharides, proanthocyanidins and free SO2 are the factors which most negatively affect foam quality.
A recent study, by means of prediction models, has also concluded that the different forms of malvidin shows the highest influence on the foam height and foam stability height parameters, followed by amino acid compounds, while foam stability model was only predicted by polysaccharides from grapes, concretely by polysaccharides rich in arabinose and galactose.
These research findings provide industry with a better understanding of the compositional factors influencing the foam quality of sparkling wines.
Biomedical ethics has made giant strides over the past decades and has come to be recognised as integral to medical education. This has encouraged the growing inclusion of the teaching of medical ethics, together with that of the human sciences, in the syllabi of medical and nursing schools. In the 1980s, increased awareness of ethical issues shone a light on some excesses of medical research and medical paternalism which conflicted with ethical principles. The 1990s saw the establishment of the first medical ethics committees in hospitals, overseeing both research and clinical practice. Since the 2000s, the various bodies regulating the doctors’ right to practice have issued regulations, guidelines and recommendations laying down formal ethical rules for medical practice, together with a system of penalties for infringement of these rules.
Many social and cultural factors have contributed to the increase in ethical concerns. The increase in individual civil liberties, codified in various Charters of Citizens’ Rights, has fuelled a growing drive to claim new rights in previously unexplored areas. The development of biomedical technologies has created new frontiers, such as the attempt to shape one’s own medical fate, as in the case of the actress Angelina Jolie, who chose to undergo preventive double mastectomy and subsequent ovariectomy because she carried a gene that greatly increased (over 80%) her risk of developing an aggressive and often fatal type of breast cancer, or the decision of a British manager to have his prostate removed for the same reason. In the meantime, the constant budget cuts have increased the need to make very complex choices.
Recently, the Covid-19 pandemic has confronted us with specific ethical dilemmas, in particular the choice about who to treat or not to treat in a health emergency with scarce resources.
The growing ethical concerns have highlighted the fact that doctors only receive very basic training in medical ethics during their studies and practical training. Some studies even show that the awareness of ethical issues of students and trainees decreases as they advance in their studies [1, 2].
Most doctors trust their ethical judgement and believe that their decisions are morally sound. Yet most doctors lack adequate training and theoretical knowledge of ethical issues to support their beliefs and choices in a manner that stands up to scrutiny. The ethical judgement of most doctors is based on their professional life experience, personal opinions, beliefs and values, but few know the theoretical foundations of biomedical ethics and moral decision-making.
The first part of this paper outlines the key theoretical concepts framing ethical decision-making by physicians. Next, the principles governing the ethical decision-making process are presented. This is important because ethics is not only about the medical decision, but also about the process for reaching that decision. Certain issues in the application of ethical principles and the challenges brought by current events to medical ethics are also discussed.
The birth of bioethics as understood today is closely linked to the giant strides made by the biomedical sciences and technologies (most notably molecular biology and genetic engineering) around the 1970s.
The gradual unlocking of the mechanisms of life, coupled with the possibility of manipulating and modifying living beings, enabled a number of procedures that gave rise to widespread ethical concerns: medically assisted reproduction, tissue and organ transplantation, genetic intervention, the possibility of artificial life independent of ‘natural’ life, euthanasia, cloning, etc.
The word Bio-Ethik was coined by German Protestant pastor and ethicist Fritz Jahr, who used the term to propose a new bioethical imperative that extended to all living beings Kant’s categorical imperative of respect for all persons [3, 4].
However, the current meaning of bioethics can be ascribed to American oncologist Van Rensselaer Potter, who used this term in a paper entitled Bioethics: the science of survival [5] and later in his best-known work Bioethics: a bridge to the future [6].
According to Potter, building an ethic based on scientific knowledge is necessary to ensure the very survival of Homo sapiens, which could be threatened if research were allowed to proceed unchecked and unfettered. Potter rejected merely speculative knowledge and stressed the need to connect ethical values, traditionally confined to the realm of the humanities, with biological facts and thus build a ‘bridge to the future’.
Potter himself defined bioethics as the ‘knowledge of how to use knowledge’, to highlight the distinctive nature of this discipline as a dialogical meeting point between the natural sciences, the social sciences and philosophy.
In his subsequent book, entitled Global Bioethics, Potter made the by now well-established subdivision of bioethics into three branches: medical ethics, environmental ethics and animal ethics [7].
It is interesting to note that originally, the scope of bioethics was not restricted to medical practice, even though in subsequent years this came to be considered its main, if not exclusive, area of concern. Indeed, differently from Potter’s definition of bioethics (later followed by Jonas in his work The Responsibility Principle [8]) the term has mostly been applied in the narrower sense given to it by Dutch obstetrician Andre E. Hellegers, co-founder of the Kennedy Institute, who considered bioethics as ethics applied to the biomedical sciences [9]. This narrowing of the scope of bioethics from its original reflection on the ethical problems relating to life, ‘bios’ in all its complexity, is partly due to the fact that the two centres where bioethics research and teaching were first developed (the Kennedy Institute in Washington and the Hastings Center in New York) focused on medical issues, specifically, on medically assisted reproduction. This meant that issues such as the treatment of animals or environmental risks were not considered to fall within the scope of bioethics proper.
The close links between the different facets of bioethics and the high complexity of the problems addressed require constant cross-disciplinary dialogue among scientists and scholars from a range of disciplines such as philosophy, law, economics, sociology, ethology, psychology and anthropology [10].
The interdisciplinary nature of bioethics is also in evidence in the current definition of this discipline, contained in the 2nd edition of the Encyclopedia of bioethics: ‘Bioethics is the systematic study of the moral dimensions - including moral vision, decisions, conduct, and policies - of the life sciences and health care, employing a variety of ethical methodologies in an interdisciplinary setting’ [11].
The relationship between ethics and science is certainly at the heart of philosophical reflection and may be summed up in one question: should we do everything we can do?
In the United States, the debate on ethical issues had already started long before the breakthroughs in genetics: it was prompted by news of gross abuses committed in several clinical trials, namely at the Jewish Chronic Disease Hospital in Brooklyn, the Willowbrook State Hospital in New York and in the famous ‘Tuskegee Study of Untreated Syphilis in the Negro Male’ which began in 1932 and continued until 1972 [12].
However, the historical roots of bioethics and, in particular, of medical ethics, can be traced further back in time by a deeper examination of the relationship between science and ethics.
The atrocities committed in the experiments on concentration camp prisoners in Nazi Germany dramatically revealed, well before the later events that prompted the appearance of the term ‘bioethics’ in the literature, the need to investigate the relationship between ethics and science.
The Nuremberg Code was the first document to enshrine in specific rules the ethical principles that govern research on human subject. The Code, which although it never attained legal value has a universal moral value, established for the first time the following standards for human experiments:
The voluntary consent of the human subject is absolutely essential: this means that the person involved must be given detailed prior information about the nature, purpose, duration, means and risks of the experiment;
the experiment must be justified in terms of necessity, anticipated results and avoidance of injury;
the risks of the experiment must be carefully weighed against the expected benefits;
the personnel conducting the experiment must be appropriately trained and qualified;
appropriate equipment and facilities must be used;
it must be possible to bring the experiment to an end at any time on the initiative of either the human subject or the scientist.
Thus, the Nuremberg Code is a landmark document in the development of medical ethics, paving the way for a gradual and profound revision of the doctor-patient relationship in order to shed the traditional paternalistic approach in favour of the principles of consent, shared decision-making and therapeutic alliance.
Following the Nuremberg trial and the consequent drafting of the Nuremberg Code (1946), several international instruments on human rights were drafted, starting from the Universal Declaration of Human Rights (1948), which laid down the first legal principles of bioethics. The Declaration contains strong statements on the right to life and physical integrity, together with other fundamental civil and political freedoms. In so doing, it opened up a new legal and regulatory path for bioethics and inspired and influenced the subsequent development of international legislation.
The global and regional documents, charters, declarations and conventions that followed explicitly refer to the Universal Declaration of Human Rights as the foundation of their statutes and precepts, including the WMA Declaration of Geneva and the International Code of Medical Ethics of 1948 and the WMA Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects of 1964 (with its several subsequent amendments.
However, with regard to the aims of bioethics, it would be reductive and historically incorrect to limit its statutory, founding aims to the need to fix the ethical boundaries for the technical progress of science. As Mori [13] pointed out, what the Nuremberg trial itself so dramatically exposed is the need to set limits not to the technological advances of science but to the abuse of those advances. Thus, Mori reminds us that the core problem of bioethics is not to trace the boundaries of technological advancement, pitting science against ethics, but to identify the reasons that justify a specific moral judgement. Thus, as remarked by Schiavone [14], a crucial premise for any ethical approach to be legitimate and justified is that any critical reflection on scientific areas and disciplines should originate and develop within science itself and the scientific and technical advances achieved by it, instead of referring to a source of regulation outside science.
Far from being a system distinct from science and which attempts to stem its progress, bioethics aims to pursue critical and coherent reflection on human dignity, as an instrument of moral control (in the secular sense) over science in terms of its impact on human beings and the environment.
The subject matter of bioethics (which concerns itself with the sphere of ‘bios’, i.e. living beings) is associated with the theme of the destiny of human beings, and thus is an emotionally charged topic, inevitably subject to strong pressures. Bioethics is constantly at risk of sliding from the role of neutral and unbiased observatory – to the extent that such a role can effectively be achieved and maintained – onto the dangerous terrain of ideology and its associated dogmatic views.
Returning to the question of the origins of bioethics, it should be noted that ethical reflection in medicine dates back to long before Potter’s text. The Hippocratic oath is significant evidence of this. The oath, which evidently reflects the philosophy and culture of a time when the medical profession had a hieratic character, contains the seed bioethics in its principles of non nocere (i.e. ‘do no harm’ to the patient) and ‘beneficence’ as cornerstones of the doctor’s activity.
The Western world has adopted this approach and has formulated codes of medical ethics and laws inspired by ethical principles to regulate the exercise of the medical profession. These sets of rules are regularly updated in response to cultural and ethical developments and to the growing demand for professional standards to safeguard not only the interests of medical professionals, but also, and most importantly, those of their patients.
In this regard, medical ethics and standards of professional conduct play a major role in the physician-patient relationship. This is the setting where protecting the patient’s fundamental rights is crucial and where the risk that medical practice may infringe the individual’s rights protected by the Constitution is highest. Indeed, since ancient times, the power imbalance inherent in the patient-provider relationship has required a framework of principles and rules specifying the physician’s duties, in order to protect the patient (Figure 1).
Main documents on medical ethics.
Ethical theories can be grouped for simplicity into two main currents.
One is teleological ethics. Teleological theories focus on the purpose of the decisions taken and on their positive and negative impacts, and assess the consequences of the action [15]. These theories are deductive and pragmatic. Among the best known are John Stuart Mill’s utilitarianism [16] and American principlism [17]. The latter is undoubtedly one of the most widespread currents in medical ethics, at least in the United States, and will be discussed below. These theories focus on doing good for each individual, but also for the community.
The second current is deontological ethics; this differs fundamentally from the teleological approach in that its focus is not on achieving a good outcome but on doing what is morally right. The deontological approach is based on a series of ‘prima facie’ principles; it is an inductive principle focused on processes rather than on the final decision and it refers to the theories of Kant and Habermas [18]. Deontological ethics recognises absolute prohibitions, which admit no exceptions for any reason, override other duties, are fixed ‘a priori’ and are unchangeable. However, since conflict may arise between different duties, priorities must be identified in the hierarchy. Thus, a shift occurs from a hierarchy with absolute ‘a priori’ duties to an ethics with ‘prima facie’ duties, which also requires examination of the circumstances.
Teleological ethics and deontological ethics are two alternative ethical theories that determine the moral good or evil of an action.
The key difference between the two theories is that teleological ethics weighs the good or evil of an action according to its consequences. By contrast, deontological ethics determines the good or evil of an action on the basis of an examination of the action itself. Its vision is based on rules that determine the action.
Application of these two theories to end-of-life care can help to clarify the difference between them. Under the teleological framework, doctors who practice assisted dying focus on the purpose of decisions. They respect the patient’s choice to end her suffering when there is no hope of improvement. By contrast, under the deontological approach, doctors may refuse to provide assisted dying care on the basis of the a priori principle that doctors are trained to treat and not to take life. These are two diametrically opposed positions, which require different ethical frameworks.
General principles that state universal values of common morality also contribute to the basic reasoning on medical ethics . Beauchamp and Childress [17] have identified a model consisting of four moral principles that constitute the most common framework for achieving what is ‘good’ and what is ‘right’ in healthcare. ‘Principlism’ is a basic framework because it identifies four fundamental principles that come into play in most medical decisions, across the different medical specialities, countries and continents. These principles do not constitute a moral system or theory, but offer a framework for reflection on the moral problems encountered, and provide a starting point for making a moral judgement and assessing the procedure to be followed. The main principles are:
respect for autonomy/the individual
beneficence
non maleficence
justice.
The principle of autonomy refers to liberal thought, which has always emphasised individual rights and freedom of choice as an expression of the individual’s free will. The patient is recognised as possessing critical thinking and decision-making skills that must be respected. The model that emphasises the autonomy principle aims to oppose and overcome the paternalistic approach that has long dominated the doctor-patient relationship. The paternalistic model was based on an asymmetric relationship between the doctor (acting as a good parent) and the patient, who was treated as a ‘child’, unable to make decisions because of his lack of scientific and, especially, medical knowledge. This model has been discarded by reversing the patient’s role, from a passive one, to that of an autonomous person, capable of self-determination according to the principle of individual autonomy. The principle of autonomy ensures that the patient is involved in the medical decision-making process and protects his right to choose, accept, refuse or stop treatment. This is an absolute right of the individual, even where the refusal or interruption of treatment might cause adverse health consequences or even death. Autonomy implies respect for an individual’s physical and mental integrity. A person cannot be forced to receive treatment against her will. The patient cannot be subjected to any physical or mental coercion. The principle of autonomy also underpins the patient’s right to accurate and exhaustive information on the proposed treatment. Recognition of this right has led to development of the informed consent procedure. However, for certain specifically identified medical conditions that pose a public health threat, the government has the coercive power to impose treatment; this can occur, for instance, in the case of acute psychiatric patients or highly infectious diseases. However, even in these cases, the dignity of the person must always be respected. To apply these rules, doctors must know the legislation in force in the country in which they work; in any case, they must take all proper actions to minimise the need for coercion and maximise the patient’s consent.
The principle of beneficence states that the patient’s well-being is the ultimate goal of care. This principle lies at the heart of medicine, whose mission is precisely to prevent, diagnose and treat illness in order to promote the patient’s health. It is a question of proposing a treatment that is proportionate to the patient’s needs and whose benefits for the patient outweigh its possible harms. This principle means that doctors may act in the patient’s best interest also by refraining from acting and/or by acting prudently, always from the viewpoint of the benefit for the patient. Traditionally, this principle has been focused on ‘objective’ good, i.e. the outcome considered to be good by the doctor. However, cultural and ethical developments have gradually led to add to this principle that of autonomy, supporting a more subjective interpretation of the patient’s ‘best interest’.
The principle of non-maleficence has been well known to doctors since the time of the Hippocratic precept of primum non nocere. Non-maleficence encompasses two key concepts. The first is that of not causing harm to patients, even before doing them good. The second is the need to properly assess the risks and the benefit/risk balance of a treatment, and hence to refrain from prescribing a treatment that, although effective, could be harmful to the patient.
The non-maleficence principle is reflected in a number of legal provisions regarding wilful medical malpractice, where the patient was intentionally injured, or negligent malpractice, where the harm was caused by negligence, inexperience, recklessness or failure to comply with laws, regulations, orders or standards.
The principle of justice requires that all people be treated fairly. It is difficult to provide a single definition of justice, as various theories have produced different versions. Egalitarian theories stress the importance of universal access to basic necessities [19]. Libertarian theories affirm the right to social and economic freedom [19]. Utilitarian doctrines require the balancing of the two principles in order to maximise public and private utility [17]. Moreover, the principle of justice includes the concept of distributive justice, which states that resources should be allocated so as to ensure that access to care is not affected by socio-economic, ethnic or other factors which could favour certain sectors of the population to the detriment of others. The problem of resource allocation arises at different levels. For example, a national government decides which share of funding to allocate to finance social and healthcare relative to other sectors such as education, labour, transport. Moreover, the healthcare budget is in turn distributed differently among the different specialties. Thus, in practice, implementing the distributive principle raises complex issues; for instance, to what extent can expensive experimental treatments be justified in patients who have not responded to conventional approaches? Some of these treatments can cost more than €100,000 per year and clearly erode the sums available to treat other patients.
These four principles are not independent of each other. Rather, they interact in all medical situations of varying complexity, engaging in a dialectical relationship which requires their careful balancing. The clinician’s art is to fully understand how to best weigh these factors on a case-by-case basis, to reach the most appropriate decision for the individual patient.
In modern biomedical ethics, the process by which a decision is reached is as important as the decision itself. This is why it is necessary to have a clear approach that takes into account the problems to be addressed and all the persons concerned.
Figure 2 shows a decision making process according to Jonsen’s four box model for decision making which evaluates four fundamental variables: medical indications, patient and family preferences, quality of life and contextual features [20].
Jonsen’s four box for medical decision-making.
The approach proposed here is one example, among the many available, of a framework to guide the decision-making process. The approach is based on a series of questions, which are set out and explained below.
What are the facts, the circumstances? This question prompts a description of the clinical problem, concurring factors and psychosocial and environmental aspects. The starting point is awareness that the interaction is not with an illness, but with a sick person with a life history, family, affections, job and deep personal, existential and ideological values. Each participant will, in their own way, experience the impact of the decision. Clearly, at the centre of the decision is the patient, being the person that will ultimately make the decision and bear the consequences. The available options should be assessed from a clinical standpoint, considering the likelihood of success of the option chosen. For example, what are the chances that a patient with aggressive cancer will survive mutilating surgery which may have major adverse effects? Besides the purely clinical assessment, the human and emotional costs involved must also be considered.
What is the ‘spontaneous’ option? What do the patient, their family members, the treating physician, the nursing staff and the medical team want? What is the impact of pressure from fellow doctors or hospital managers, for instance in the event of a shortage of inpatient beds. What is the possible impact of pressure from the media?
What are the values at stake for each of the parties concerned? To answer this question it is necessary to draw up a personalised list of the hierarchy of values at stake, in the specific clinical situation, for the main parties concerned, mainly the patient, but also her family members (clearly where they have a say) and the medical team. For example, in the case of surgery entailing the risk of serious adverse effects and disability, the patient might refuse the surgery if she feels that the degree of beneficence, as perceived by her, is not adequate; the patient might instead wish to retain her current physical status, refusing a procedure that she considers to be invasive and destructive; this because the patient fears that after surgery, she might not recognise herself as the person she was before. On her part, the doctor may feel that the surgery will enable the patient to survive with what the doctor considers an acceptable quality of life (beneficence/maleficence). In other cases, the reverse may happen: the patient and his family members may want the surgery to be performed no matter what, even if its positive impact may be minimal or zero (patient autonomy vs. doctor autonomy vs. fair allocation of resources).
What is the moral dilemma? The matter here is not to choose the best course of action, but to identify clearly the moral dilemma faced by the doctor and the whole team, spelling it out in the most explicit and detailed way. What must be decided is not whether to operate on a patient who demands a treatment that will yield little or no benefits, but whether to prioritise the patient’s autonomy, and what he considers to be beneficial, or to prioritise the professional autonomy of the doctor, expressed through his clinical judgement on a procedure that he considers to be maleficent (a useless operation that will cause suffering to the patient) and to entail an unfair allocation of resources.
What are the alternatives? All too often, emotionally charged situations lead to a polarisation of views between just two possibilities. In the example in point 3, the only two options considered are surgery versus non-surgery. Instead, all options should be considered and presented to both the patient and his family members: chemotherapy, palliative care, home care, etc.
Which was the initial spontaneous choice? It is always advisable to return to the first spontaneous choice and assess whether the position of the main parties has evolved, and whether they have moved closer or farther apart from each other or have otherwise changed their views. If a change of position did happen, it should be considered whether this could help to reduce the conflict.
Making the decision. The decision must be made after consultation with the main parties involved, first and foremost the patient, but also his family members (where their involvement is authorised by the patient), the medical team, etc. It is important to have an open attitude and to truly listen. The patient must be seen not only from a medical point of view, but as an all-round individual with a life story, beliefs and concerns. As J. F. Malherbe [21] said, the patient remains the protagonist of his illness and not just the object of treatment. One should not hesitate to consult a colleague to get a second opinion, or even the hospital’s ethics committee. After exhausting all these steps, a decision must be made. The decision must be justified by taking into account the medical evidence for each situation, but also the ethical issues specific to the situation. It is essential to specify which elements justify the principles that were given priority in the decision-making process.
In theory, the description of ethical principles seems to give a clear overview of medical ethics and the procedures to be followed when making treatment decisions.
However, in clinical practice, the application of ethical principles is increasingly complex and is often affected by issues that complicate the decision-making process and come into conflict with ethical principles. Some issues arise when different principles clash with each other; others are linked to patient-specific situations, while yet others are linked to the organisation of services.
With regard to the conflict between principles, a common opposition may arise between the principles of autonomy and beneficence, for example in terminal cancer patients. According to the principle of autonomy, the patient should be told that her condition is now terminal, to allow her to freely choose among treatment options and decide what to do with the time she still has to live. However, under the principle of beneficence, one might argue that providing such accurate information might cause deep pain, and hence be harmful to the patient, affecting negatively her will to live and her quality of life in the time left to her. Moreover, the conflict between the two principles is not an abstract one; on the contrary, it is experienced by the parties to the decision-making process, with real consequences. The principle of autonomy can be interpreted in very different ways by doctors. For example, some doctors might resort to the legacy of medical paternalism and feel authorised to deliver all the bad news to the patient; other doctors could rely on the principle of autonomy to avoid making difficult decisions by shifting the responsibility onto the patient and/or her family members, placing a heavy emotional burden on the patient; still other doctors may not provide the full set of options to their patient to prevent her from making decisions that the doctor does not consider beneficial to her, resorting to a sort of ‘palliative paternalism’ [22] and thereby arbitrarily reducing the patient’s free choice.
Conflict may also occur between the principles of beneficence and non-maleficence. An example is found in pain management for terminal patients, where the use of opioids relieves pain and meets the beneficence principle, but may shorten life, thereby violating the non-maleficence principle. Both principles are not absolute and are often combined, as in the above example, giving rise to the ‘double effect’ phenomenon, a term that in bioethics refers to an action that can have more than one result and contrasts two principles [17].
Other issues in the application of ethical principles arise when healthcare systems have to contend with limited resources. In these cases, the first ethical problem is patient selection for access to and discharge from care, which clashes with the principles of beneficence, non-maleficence and justice [23, 24]. The American Medical Association [25] has provided guidance on the ethical implications of the allocation of organs for transplant, which may be helpful in the task of determining priority of access to scarce and costly medical resources. The AMA paper has identified five criteria related to the patient’s Medical Needs, which should be considered when making resource allocation decisions: likelihood of benefit
the improvement in quality of life
the duration of the benefit to the patient
the urgency of the patient’s condition
only in some cases, the amount of resources required for successful treatment
These criteria help to maximise three primary goals of medical treatment: number of lives saved, number of years saved and improvement in quality of life. A hierarchy of objectives prioritises the goal of saving the greatest number of lives. [25] While the AMA document makes an important contribution to ethical decision-making, many questions about distributive justice and discrimination against older people remain open.
Furthermore, major social changes have affected the organisation of health systems and have further complicated the application of ethical principles. The globalisation of modern society, with its marked contradictions, inequalities and injustices has also inevitably affected healthcare systems. The undoubtedly successful McDonaldization phenomenon, [26], characterised by efficiency, productivity, cost reduction, procedural standardisation and control, has also influenced the organisation of healthcare services. The double pressure to cut costs and make a profit has impoverished the healthcare system, hitting hardest the most vulnerable and deprived citizens and generating major inequalities in the access to healthcare services: this has deeply affected the ethical principle of justice and beneficence and has altered the doctor-patient relationship [27].
In 2020, the whole world was struck by the Covid-19 pandemic. The pandemic disrupted life for every person with an unexpected, novel situation and caused an unprecedented humanitarian emergency. Its sudden outbreak has put the health systems under massive strain, causing a number of ethical problems for healthcare staff and managers, and giving rise to real challenges to basic ethical principles.
Compounding the existing problems in applying ethical principles, the pandemic has brought about new complex scenarios and issues, which have not always been addressed appropriately and in line with ethical principles.
The first moral dilemma posed by the pandemic relates to the strain on healthcare quality caused by the surge in demand. The pandemic has spread quickly, catching the health structures unprepared to handle the rapid increase in workload. At the height of the crisis, the number of patients rose dramatically and the hospitals soon ran out of beds. The number of healthcare workers (doctors and nurses) was also insufficient to deal with the surge in cases. Many health workers faced the additional workload with great dedication and sense of responsibility, aware that their patients’ lives also depended on their willingness to put in the extra hours. They prioritised the beneficence for their patients over their personal well-being. Many healthcare workers fell ill and many died [28]. At the peak of the pandemic, medical and nursing staff worked 12–14 hours a day wearing uncomfortable face masks, visors and coveralls. It is fair to assume that fatigue and stress at work may have affected the quality of care, hence the actual beneficence for patients. It can also be presumed that the quality of the care provided at the start of a work shift was higher than that provided by the same worker after 12 hours of gruelling work. Thus, the actual working conditions undermined both the principle of beneficence and the principle of justice, according to which all patients must be treated equally.
Moreover, the spike in patient numbers was so high that it produced an imbalance between the healthcare needs of the population and the availability of intensive care resources. The situation that came about was and still is an exceptional one, to the extent that it has been classified as ‘disaster medicine’ [29]. With regard to intensive care, in addition to the criteria for access to and termination of care, traditionally based on the appropriateness and proportionality of care, the criteria of distributive justice and appropriate allocation of limited health resources had to be applied. The ‘first-come, first-served’ criterion for access could not be applied. Healthcare workers were forced to carry out an unusual triage, in which they often had to apply the criterion of ‘greater life expectancy’. In Italy, SIAARTI (the Italian Society of Anaesthesiology, Analgesia, Resuscitation and Intensive Care) issued ‘Clinical ethics recommendations for the allocation of intensive care treatments, in exceptional, resource-limited circumstances’ [29]. The recommendations are solidly grounded in ethical principles, to relieve clinicians from the burden of making subjective decisions, and establish explicit resource allocation criteria [29]. (SIAARTI). Robert et al. highlighted the ethical issues in patient management in intensive care units during the pandemic in France [30]. Despite the guidance provided, the dramatic pressure of the situation often forced physicians to grapple alone with the final decision about who should get life-saving care. While admittedly it was necessary to make a selection among the patients, we must also note that a dramatic discrimination occurred by age group, comorbidity and patient type. Elderly patients, patients with comorbidities and frail patients were often denied access to the ICU.
The pandemic emergency also gave rise to other issues. Many patients could not even reach the hospital and died at home while waiting for an ambulance that never arrived. In those cases, the decision was not guided by any particular and specific recommendations, but was simply left to chance: the lottery of life decided for them.
For the patients’ protection, during their stay in hospital, the patient-family and healthcare worker-caregiver connection was severed, counter to more than 20 years of research and care practice aimed at improving those relationships for the patient’s benefit [30]. Many patients were left to face death alone, without the comfort of family members, without any spiritual or religious care. As hospitals were overwhelmed, much was attempted to provide the benefit to the body but little was done to provide psychological and emotional care; healthcare moved back from caring for the whole person to focusing on the illness alone.
Yet other decisions have impacted ethical principles and good clinical practice in the management of chronic patients. For a long time now, the healthcare system has placed emphasis on prevention and early diagnosis programmes, educating the public about the importance of health screening and monitoring. The emergency has deeply disrupted this approach. Many cancer patients have been unable to attend their routine checks, and the same has happened to patients with heart conditions or diabetes. The principles of beneficence and non-maleficence have been severely compromised. An increase in deaths due to cardiovascular diseases has already been recorded, and the number of deaths secondary to cancer is also expected to rise [31].
The above overview confirms that the practical application of ethical principles in medicine is fraught with difficulties that may complicate the decision-making process. The current pandemic is confronting us with novel organisational, social and ethical challenges.
As a rule, major changes in healthcare occur at a much slower pace, giving us enough time to process them, adapt and make decisions. Today’s explosive crisis calls instead for urgent emergency measures. The assessment tools we have used so far have been made obsolete by the extraordinary pace of the crisis. In the health sector, clinical guidelines have traditionally been the gold standard for good clinical practice, in addition to providing some protection from medical liability. However, many guidelines have lost their relevance in the pandemic, which has created an unprecedented health situation for which no specific guidance could be prepared. The dramatic developments have put ethical principles under strain in various circumstances and cases. Moral dilemmas have severely affected the emotional resilience of clinical staff; in the near future we will have to deal with the moral distress they experienced.
Ethics, once a discipline of interest to scholars, has nowadays taken on a prominent role in the social debate. However, moral questions must be addressed and analysed critically, in order to define not only what is right, but also why it is right. [32]
Hopefully, we can draw some lessons from this tragedy.
The rationalisation of healthcare resources – through major budget cuts, the push for standardised care processes according to the McDonaldization model, the emphasis on hi-tech and highly specialised care – has not withstood the test of the pandemic. While of course it is hard to say which model would withstood the Covid crisis, it remains a fact that the current one failed, and this requires some reflection.
First, we should strengthen the human dimension of the physician-patient relationship. The focus on performance and profit has reduced the time available for listening to patients and their family members; as medical professionals, we have contributed to the achievement of the productivity targets set by the health authorities, but we have not always respected the ethical principles of an authentic doctor-patient relationship based on caring for the individual as opposed to simply treating a medical condition. Health professionals should take the brave step of fostering the relationship with their patients and prioritising quality over quantity, eschewing the industrial assembly line model: people are not machines and do not function like machines.
Social systems as a whole should revisit their resource allocation models. For a long time now, policy makers from all sides have made major cuts to health care; the pandemic has shown that ‘sick countries’ with difficulties in the delivery of healthcare are also countries with persistent economic problems. The share of public spending allocated to healthcare should be fairer, instead of treating the health service as the poor relation.
During the pandemic, we helped the patients with the greatest chance of survival, but we were unable to help the frailest ones. We went back to the model of Sparta, the ancient Greek city where frail male infants were tossed off a cliff, to train the others to become strong and valiant warriors. However, the Spartan model was not the one that prevailed in ancient Greece, nor the one that produced the greatest protagonists of classical culture. Healthcare systems, with the contribution of medical ethics, should develop care models that protect the frailest and shelter them from ‘competition’ for survival in which they would be doomed from the start.
We should also send the message that medical ethics is not just a matter for the individual health professional but is the responsibility of the whole community. The pandemic is teaching us that the responsible behaviour of each of us plays a key role in preventing the spread of the infection. The principles of medical ethics, beneficence and non-maleficence should be better known, understood and applied not only by health workers but by all persons.
Last but not least, the expectations placed on doctors today are very high, if not excessive, as concerns both clinical skills and patient relations. Although ethical issues are now on the front line, there is still very little training in biomedical ethics for health professionals. The development of science and technology require that physicians be knowledgeable of ethical issues pertinent to end-of-life care [33, 34]. It is crucial to invest more in this of training, to ensure that the new generations of doctors and other health professionals, within their respective roles, are better equipped to face the new challenges for medical ethics.
This is a brief overview of the main steps involved in publishing with IntechOpen Compacts, Monographs and Edited Books. Once you submit your proposal you will be appointed a Author Service Manager who will be your single point of contact and lead you through all the described steps below.
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