The Physician’s Imprimatur

In a previous blog response about physician-assisted suicide (PAS), Mark McQuain asked, “Why involve physicians at all?” That question gets too little attention.

There are some easily discernible (and perhaps expressed) reasons why physicians are chosen to be the agents of assisting suicide. First, they have access to pain- or consciousness-relieving pharmacologic measures that also have the (in this case) desirable effect of stopping breathing when given in high enough doses. Second, by their professional ethic, physicians should approach patients with compassion, which, as mentioned previously, is the catchword that is quite deliberately attached to the act of assisting suicide by those who promote it.

But as Dr. McQuain suggests, access to painless methods for killing need not be restricted by to physicians, just as compassion is not; there is no law of physics that prevents others from assuming this role. To limit the methods and the responsibility to physicians is a willful act by society.

This leaves one main reason for committing the responsibility of assisting suicide to physicians: involvement of physicians gives it a much-desired moral certification, or imprimatur. Here is the logic, unspoken as it is:

  • Physicians have moral standing;
  • If physicians are involved,
  • Then the act has moral basis

But this gets it backwards. Physicians have moral standing based on what they do and what they refrain from doing. Edmund Pellegrino wrote often of the “intrinsic morality” of medicine which depended on the nature of the physician-patient relationship. Such morality stems as much from what is not done as from what is done.

We need not agree upon any particular bioethical issue to realize the significance of the tactic, in how it can could be used by proponents of various acts to enlist, and yes, even pressure or legally mandate, the involvement of physicians. Or, for that matter, the involvement other people whose life work is viewed by society as having moral standing.

If PAS were to be legal across the US, would physicians buy into the idea that it is consistent with the underlying ethic, or intrinsic morality, or their practice? I predict that most would not. Recall the vision of abortion (when first made legal by judicial decree) being done by the patient’s family physician, which presumed a longstanding benevolent and wise relationship. This of course failed to happen, and abortions have since become centered in facilities where patient and doctor remain, by no accident, strangers. Most physicians do not want to be associated with abortions ( and none of the many family physicians I’ve met) because they know that there is a quality to the act that impacts them; it would not be benign simply because they did it. And it is not consistent with the underlying moral and ethical basis for their medical practice.

So it will be with physician-assisted suicide. The strategic involvement of physicians will most certainly mean that some will be involved. But most who could be involved will decline, knowing, or at least sensing, the inverted logic behind how physicians got pulled into the affair to begin with.

How Far Can We Fall If There is No Bottom?

A May 26th post in the Bioethics Forum of The Hastings Center asks “Are we reaching a tipping point in the debate over physician aid in dying?” The author cited the case of a Cornell psychologist who opted to commit suicide with physician assistance before Alzheimer’s caused her to lose “all quality of life” and “meaning.”

Cases such as these are compelling, because aging, infirmity, and dying are so. Each instance causes distress, and to remove distress seems to be the ultimate humanitarian act.

We must ask, however, why Hippocrates thought it necessary so long ago to include in the physician’s oath the injunction against assisting suicide. What was it he saw that made it necessary to draw this bright line? Certainly suffering was at least as common then, as physicians did not have nearly as many tools to alleviate it. For Hippocrates to draw this line in the face of suffering, he would have had to see how far physicians could go in willfully causing their patients’ deaths, and the consequences of such actions on the profession, the community, and the relationship between them. We don’t see such problems today, as we are still living off the fruit of that ethical standard.

In ethics we ought to consider the importance and value of clear lines such as those written into the Hippocratic Oath. They do not guarantee that nothing undesirable will happen. They do, however, serve as a floor, guaranteeing that professional conduct will only fall so far. If removed, what then becomes the insurance that we will not step lower and lower?

Many years ago I spoke with the head of a large shelter for the homeless. He had an impressive background, retiring from the Army where he had served in the Rangers. Driven by the imperative of his Christian faith to aid his fellow man in need, he had become a nurse and eventually in charge of this shelter in a Georgia city. I asked him what was it that he saw that worried him the most. He said, “Youth today have no bottom.” After I asked him to explain, he said that many youth so lacked any moral foundation that there was no depths of depravity to which they couldn’t fall. A few months later was Colombine.

We could debate in detail each of the author’s premises, such as claims as to what is “quality of life,” or “meaning,” or the role of physicians. One thing we must recognize, however, is that line drawn so long ago by Hippocrates has served as a “bottom,” preventing physicians from plumbing the depths of increasingly abhorrent acts. In discussions of PAS, proponents of it extract the positive feelings and leave the scene before the unpleasant consequences emerge. Hippocrates must have known those full well, and with that knowledge wrote his oath. I fear that we will soon regain that knowledge…the hard way.

Dying and Dignity

On November 1st, Brittany Maynard, a 29 year-old Oregonian with an incurable brain tumor, took her own life using a medication prescribed by a physician specifically for this purpose. The medication, legal under the Oregon’s Death With Dignity Act, was prescribed weeks earlier.

The case is well-known because Brittany became a spokesperson for efforts to expand “assisted suicide” laws to other states. Through her own efforts, her story appeared in numerous publications and websites, and has been held up by the organization “Compassion & Choices” as exemplifying the justification for making assisted suicide legal nationwide.

Brittany feared many things about dying with brain cancer—her own physical pain, progressive debilitation, dependency, seizures, as well as emotional pain for her family. To avoid these through her own choice, was to die with “dignity”. This term has been held tightly by assisted suicide advocates, such as by the Swiss group “Dignitas”. The organization “Compassion & Choices” holds to a few more terms it wishes to apply to assisted suicide.

When reading the stories about Brittany it is difficult to bring oneself to find fault with her decisions, knowing the heartbreak that she and her family were going through. It is as if such conversations themselves are too painful, and so, like Brittany Maynard did of her life, we terminate them before they’re complete.

But there is much to critique about “assisted suicide”. What is striking is the usurpation of terms, most notably the term “dignity”. It is a shallow interpretation indeed, for according to the website http://www.thebrittanyfund.org, to die with dignity is to die “in control”. The term “dignity” is reduced to describe the ultimate act of autonomy. To give it the imprimatur of compassion and approval, a physician prescribes the fatal medication; we know full well, however, that physicians are not necessary participants should one decide to end his or her life.

Real dignity is much more. I thought about the young Mrs. Maynard today after I visited a friend dying of cancer. And I thought back to my own parents’ terminal illnesses, including one with a tumor in the brain. Somehow I can’t fit the term “dignity” into any circumstance in which one of them would have willfully avoided their final moments. Those are painful days, hours, and minutes, but precious nonetheless. They bring us together, force us to cast off trivialities, and sharpen our focus on what is most important. They call out the best in us, and send us away with a sense of something greater…including perhaps a resolve to make something more of the life we are given. After all, why does God give us death but to remind us how to live?

My wife said of my mother, “She showed us how to die.” There, in a debilitated and helpless state, was true dignity. I am eternally thankful for every moment.

Physician assisted suicide on YouTube

Physician assisted suicide (PAS) is in the news in a way that is different than before. It is not because it is election time and a state has a ballot initiative about legalizing PAS. It is because a 29 year old woman with an aggressive malignant brain tumor, Brittany Maynard, has chosen to use PAS to end her life and chosen to do it very publicly by using her story to promote the legalization of PAS in a video about her choice produced in cooperation with the euthanasia advocacy group Compassion and Choices.

The video focuses on her desire to be autonomous. She states very clearly that she wants to be in control of the circumstances of her death and that she considers it her right to choose the manner of her death. There is no denying that PAS can be seen as the ultimate act of autonomy. The question is whether insisting on our own autonomy and being in control is what is morally right. God has given us the ability to make choices and he allows those choices to have real effect, but that does not mean that all choices are good. We can at times exercise our autonomy in ways that are not good. We can be prideful or controlling or self-centered. I say we because I am not saying that this particular person’s choice necessarily involved those wrong motives. It is simply that as fallen human beings our autonomous choices often involve those things and are wrong. One hint of what underlies Brittany Maynard’s choice is found in the section of the video in which her mother begins to cry when she talks of her daughter convincing her to take a trip to Machu Picchu where the mother is afraid to go by telling her that she will meet her there. There is a suggestion that she desires not only to control her own death, but her mother’s life as well.

A second video that was released a few days before the day Brittany Maynard had announced she was going to end her life is addressed to her by Maggie Karner, a woman in Connecticut who shares with her the diagnosis of stage 4 glioblastoma multiforme and will also soon die of her brain cancer. Her video, which was produced by the Family Institute of Connecticut (an advocacy group for traditional Judeo-Christian family values), pleads with Brittany not to end her life, but to live out as much of it as she can. Her perspective is that life is valuable and living life, even when autonomy and ability are impaired, is meaningful to her family and others who love her. To make her point she relates the story of her father who lived for five months after becoming quadriplegic and tells of how much the intimacy she shared with her father during the time she helped care for him in his helplessness meant to her. She does not condemn Brittany for her choice but calls out to her like one would call out a plea not to jump to someone preparing to jump off a building (her analogy).

Unfortunately Brittany Maynard did not head that call and took her life a few days later.

What’s so good about Good Friday? Good Friday and Bioethics

“Why is it called Good Friday?” my ten-year-old son asks. “What’s good about it?”

What, indeed. The day we remember a death — and not what people usually mean by a “good” death. When people speak of a good death, they usually mean either that the one dying didn’t die too young or with too much suffering, or that it was as “least-bad” as possible for the family. But even a “good” death is still a long ways from our usual definition of Good: there is still a corpse lying there, and there are always those left behind who are mourning a loss, always people that have been deprived of the presence of a father, spouse, grandmother, uncle, friend.

On Good Friday Christians remember a death that seems anything but good. It is the memory of the death of a man who showed what Love was like in a way that nobody else ever had; a man who healed, who taught, who shone the light of Divine life into the world in a way that nobody else ever had. A young man, in his prime, who moreover died an unjust death at the hands of jealous, scheming enemies; who died a horrible, protracted death on a Roman cross, stretched out, exposed to the elements and the derision of his countrymen.

“Why is it called Good Friday?” Because Christians understand that out of this irreconcilably terrible death, out of what appears for all the world to be a tragedy, God was able to bring Good for all the world. Because Good Friday is followed by, and necessarily precedes, Easter, Resurrection, life from death, salvation from sin, life with God.

As a clinical ethics consultant, I am often faced with situations that seem like tragedies. Most consults to our ethics service spring from the anguish that surrounds death; a loved one is stretched out on an ICU bed for a protracted period of time, maybe tethered there by machines, exposed to all the depredations that modern medical technology has to offer. Is life possible? Is a good death possible? What is the best thing to do? What is the right thing to do?

Often, there is no readily apparent “right” or “wrong” in these situations. In fact, as Jerome Wernow reminds us, if we approach these situations only with the calculus of right and wrong, our bioethics is left lifeless, empty, tragic. Sometimes our job as ethics consultants is to try to find some way to secure some good in what seems a hopeless situation. According to Wernow, to address tragedy we must turn to mystery, to “Mystery-revealed:” Christ, in whom is Life.  The question we ask as Christians doing bioethics is not simply, “What is Good?” but “Can I bring some hint of eternal life into this tragedy?  How do I bring the mystery of Life into the abyss?”

Good Friday is good. God can bring good out of even the most appalling situations. We can’t raise people from the dead; but we can practice bioethics in a way that reflects our faith that God can work even in the midst of tragedy.

Cyber Life After Death

In The New Yorker this week Laura Parker reports on a new internet start-up that has a technological solution to a vexing old problem: mortality. Eterni.me has the tagline in huge font on its site, “Simply Become Immortal.” The CEO, Marius Ursache, says he is trying to solve the “incredibly challenging problem of humanity.”

Transhumanists like Ray Kurzweil have been arguing for a while now that it is our unique arrangement of information that makes us human—not anything to do with flesh, or emotions, or spirit, per se. Therefore if you capture those data sets and upload them, then “you” could “live” forever. The Transhumanists are more hopeful that artificial intelligence would allow the sine qua non of sentience to emerge from the machines into which our data becomes hard-wired. This Eterni.me website really only strives to maintain your “digital footprints” and through a scanned 3D avatar present a facsimile of you to those whom you choose. For example, Facebook posts, timelines, Twitter feeds , Instagram posts, and emails are all collated, and then they are “taught” to interact with your loved ones after you pass on. Not quite as nefarious a project as the Transhumanists have in mind. Think of the hologram of Princess Leia popping out of R2D2 in Star Wars, “Help us Obi-Wan Kenobi, you are our only hope.” An image with historical content meant to remind those you left behind of your absence.

This is clearly the next logical step as more and more of our relationships are limited to a virtual realm, and authentic face-to-face encounters are becoming almost quaint. Theologically, this is just a further expression of St. Augustine’s homo incurvatus in se, or humankind’s turning in toward itself rather than looking to God for salvation. It’s a classic expression for our times: a technological solution trading on our narcissistic concern that we all die and will be forgotten, utilizing our curated and projected “self-image” as portrayed online, and sent to haunt those whom we choose. While it is a little bit creepy, it is more of a barometer for the state of human affairs as we continue the secular search for meaning beyond death.

Personal thoughts about death

As Joe Gibes referred to in his 1/17/14 post, it is easy for those of us who discuss and write about bioethics to talk about death in academic terms that leave out the personal and emotional context that death involves. On 1/11/14 my wife Rachael’s mother died after many years of dementia and 5 months of having metastatic ovarian cancer. There were no ethical dilemmas involved in her death. Her husband of 65 years cared for her in their home with the help of a hospice team. She had little pain until the last few weeks and that was well controlled by their care. The decision by her surrogate decision makers to provide palliative care for her incurable cancer was not a difficult decision to make. Yet her death makes me think about some of the things we discuss in a new way.

Rachael’s mother was at peace with her death. Even though her dementia caused her to forget to she had cancer and she woke each day with the sense that she had been ill, but the conviction she was getting better, she did understand briefly when her condition was explained to her that it meant she was going to die. Her response to that was that she was ready to go to be with her Lord whenever it was time. Death was something that she had faced as a reality ever since she had been expected to die as a child of tuberculosis and lived the rest of her life with the respiratory after-effects of that. Her faith in God was strong and she was fully assured of her future life freed from the limitations of this life. Death is an enemy, but it is a defeated enemy and she knew that. Those of us in medicine who have this Christian understanding of death still see death as an enemy which we work to prevent when possible, but we need to remember that our ability to thwart death is limited and it is Christ who has ultimately defeated death.

Rachael’s father is also a man of faith who shared his wife’s understanding that Jesus had defeated death and is looking forward to eternity with his Lord, but the death of his wife of 65 years tore a hole in his heart. He had spent the past 7 years or more devoted to caring for her and her needs as her ability to care for herself gradually was taken away by her dementia and then more rapidly by her cancer. This strong man who had held up others in their struggles for decades as a pastor was broken. Tears flowed whenever he tried to speak. My wife was impacted in the same way. Suddenly with her mother’s death her whole world had changed. She knew intellectually that it was coming, but the impact was overwhelming. As we gathered as a family and many prayed those broken hearts began to be mended, but it will take a long time for hearts that have been torn apart by the death of this precious woman to heal. When we in medicine care for those who are dying it is right for us to be guided by the decisions and values of the one who is dying and when that person is incapable of making decisions the decisions about care should be made according to the best interest of the dying person and in light of that person’s values, but we need to be careful to remember that it is not only the person who is dying who is impacted by death. We need to remember the impact that death has on those who love the one who is dying and extend our care to them. The hospice movement includes that perspective in what they do and we all need to be sensitive to the needs of those who are left behind.

Life, death, technology, and really hard questions

A tragedy is unfolding in Texas, unfortunately in the public eye, of a 33-year old woman who suffered a severe injury to her brain on November 26th, when she was 14 weeks pregnant. Her brain, we are told, has stopped functioning; her other bodily functions are being maintained artificially. Her now 20-week old fetus is still alive. Her family has asked the hospital that, in accordance with the woman’s previously expressed wishes, her bodily functions no longer be maintained mechanically. The hospital has refused, citing a Texas law that prohibits the removal of life-support for a pregnant woman; the husband has sued the hospital to have the life-support removed.

Here is a tragedy in which all choices are fraught with deep sorrow, and in which difficult questions are legion; if we think we have answered one, seven more spring up to take its place. Before I discuss them any further, let me lay my cards on table: First, I am pro-life. This implies far more than that I am simply against abortion! But I do believe that in most situations, abortion is not the right or best option. Among other reasons, I believe this because I am a physician still enamored of the Hippocratic tradition, and because I am a Christian — that is, I believe Christ’s claims that he is divine, and that therefore his statements such as “Do unto others as you would be done by,” and “Whatever you do to the least of these you do to me,” are more than just suggestions, and apply to how I treat all people, whether in utero or ex utero. However, there are rare instances in which abortion is the “least bad” alternative, such as when continuing a pregnancy places the mother at risk of serious harm or even death (and while this is indeed rare, I have known patients for whom this was judged to be true).

Second, I have some pretty strong beliefs about technology, which readers of this blog may have divined. I do not believe in the technological imperative which states that “Because we can do such-and-such, we are obligated to do it.” I strongly hold that people should be free to choose not to have technological interventions performed upon themselves. Related to this, I believe “Technology creep” is a rampant problem in medicine: techniques designed for one application are indiscriminately generalized and applied everywhere they can be applied, just because they can be, just because they are technology, and because we assume that technology always makes things better — when often all it does is dehumanize the situation.

That said — of all the questions this tragedy raises, the two questions I pose today are, Is stopping life support for the mother equivalent to abortion? And a related question, Does the pro-life position necessitate holding that this woman should be kept on life support for the sake of her unborn baby? The reasons to answer Yes are compelling. There are two people on life support: one who will almost certainly never get off of it alive, and another who has the potential to get off of it alive if the other stays on a little while longer. If the machines are disconnected, two people will die. As far as we can tell, the machines are not a burden to the mother (if she is indeed “brain-dead,” then by definition she isn’t suffering). When she said that she would never want to be maintained on machines, she probably wasn’t considering being pregnant and on machines, and who knows what she would have wanted in that case? It seems it would be better to err on the side of temporarily maintaining her bodily functions for the sake of her unborn child.

And yet there are enough caveats here to make me wonder. Is stopping the life support in this situation tantamount to abortion? I am not sure that it is. By withdrawing the life support, we withdraw a technique and allow the natural course of events to take place; the intention is not to kill the fetus (although that is what surely will happen as a result).  By induced abortion, we introduce a technique to change the natural course of events, with the intention to kill a human being. It seems to me that there is enough of a difference between the two that we should not conflate them. Again – it is well-accepted that there is no ethical difference between withholding treatment and withdrawing treatment. If we are to say that withdrawing the treatment in this case is abortion, does that not imply that withholding (not starting) the treatment in the first place would also be abortion? That smacks of a tyrannical technological imperative, a place I don’t think we want to go. Again –  The second formulation of Kant’s categorical imperative runs something like, “We should never use someone only as a means to someone else’s ends.” I am no philosophy major, but it sure feels like keeping this woman on life support against her express wishes is making her a means without considering her as an end.

If one were to abstract this situation from its context, consider it as a theoretical problem, the “least bad” outcome would be for the woman to be supported until her baby is born. But this is not an abstract, theoretical problem. I have sat at the bedsides of many, many patients who have been trapped in webs woven by dubious uses of technology. I have seen many, many people enduring the “living hell” that this woman’s husband has described experiencing over the last few months. Granted, these experiences of mine don’t carry the weight of rational arguments; but they remind me that these decisions are not carried out in the academic ether. I do not believe that withdrawing the life support for this woman is equivalent to abortion; and, related to that, I don’t believe the pro-life position necessitates holding that keeping this woman’s body functioning in order to allow her baby to reach viability, against the express wishes of her and her family, is the only ethical solution. There are those who will disagree with me, some vehemently; I understand their positions and respect them. (I am not speaking for Trinity International University, so don’t get mad at them!)

I don’t have space to go into all of the other issues this situation raises (one of them being the definition of “brain death” — see here for a thoughtful reflection on the matter). But one more issue I will address: There are a lot of people who have written and said uncharitable and judgmental things about this woman’s husband and family. While I am uncertain about what is the right thing to do in this situation, I’m quite certain that passing judgment on the family is wrong.

Please don’t allow me to kill people: an open letter to Scott Adams

(Last Saturday, Scott Adams, the creator of the brilliant comic strip “Dilbert,” wrote in his blog a raw piece about physician-assisted suicide, which has created something of a stir. If you wish to read it, it is here; but I warn you, it is not pleasant reading, and it is full of profanity.)

Mr. Adams,

My deepest, deepest condolences. I don’t know you, but I am a Family Physician, and I have stood more times than I can count at the bedsides of people going through situations similar to your father’s. I have sat in too many rooms with families as their loved ones have withered away; too many times, I have been unable to offer healing, but only comfort, support, presence, and respect for the dying and his or her family.

Please don’t ask me to offer more than that. I know your blog post was written in the midst of “hideous unpleasantness,” and I can pardon your wish for me to die a slow, horrible death because I am opposed to using my power to kill people. But such extreme frustration, grief, and anger as you are experiencing is not in itself an argument for giving one class of people the right to kill others.

A long time ago, we doctors did kill people. We with the power to heal have always had the power to kill, and at one time we were allowed to use both powers indiscriminately. We were salesmen, technicians, offering whatever the customer wanted, whatever the market would bear.

But then someone, or maybe it was a group of people, who assumed the name “Hippocrates,” came out and said, “No more. We will not use our power to kill people. We know that Power can be used for good. But Power by its very existence begs to be used, and it knows no distinction between good and bad uses. We are well-meaning, but we know we are flawed. Therefore, we will place the most stringent restraints we know on our Power: we will not use our Power for killing.” And it was at that moment that we stopped being technicians and became Professionals.

But our record isn’t perfect. As recently as the middle of the last century some of our number in Germany thought we could safely use our Power to kill for beneficial purposes. And more recently, our colleagues in a few European countries — and now a few of our own states — have been given the go-ahead to use our Power (oh, so much greater now than in Hippocrates’ time) for just the purpose you advocate: to actively end a person’s life. And I must gently dispute your assertion that such policies are working “with little problems.” On the contrary, the problems those policies are facing are huge ones.

So please, don’t ask the government to give me the power to kill. I am human, like you, and, even with the best of intentions, I can’t properly handle such power. You can ask me not to abandon my dying patients. You can ask me to sit at my dying patients’ bedsides and weep at their funerals. You can ask me to do whatever I can to help their families. You can ask me to stop using unwelcome powers of healing that serve no other purpose to keep bodily functions going, and I will gladly comply; and I will use every bit of power within my reach to help alleviate pain, short of killing the sufferer. I will do it all in “com + passion,” which literally means “suffering with.”

But please don’t ask me to end suffering by using my Power to do away with the sufferer. Because there are just some things a Doctor shouldn’t do.

 

What Verdi helped me remember about end-of-life issues

Thursday was the 200th birthday of the Italian composer Giuseppe Verdi, best known for writing lots of Italian operas. To celebrate the occasion, the Chicago Symphony Orchestra and Chorus, under Italian music director Riccardo Muti, performed Verdi’s Requiem Mass. A Requiem Mass is a worship service celebrated often in the setting of a funeral; it takes its name from the Latin prayer used at the beginning of the Mass, “Requiem aeternam dona eis, Domine” (“Grant them eternal rest, O Lord”). Verdi, like many other composers, set the prayers of the Mass to music. (When a Requiem Mass is performed in the concert hall, it is those musical prayers that are performed, not the entire service.)

I was blessed to have tickets for this concert; but I am not a huge fan of the operatic style of singing, so I was unsure of what the experience would be like.

I did not expect to be overwhelmed, deeply disturbed, shaken to my core, profoundly moved — and these do not begin to describe what I went through. In 90 minutes, in ancient words and incomparable, sublime music, Verdi made us undergo the range of emotions associated with death: terror, awe, suspense, desolation, worshipful joy, heartbreak, longing, desperation, pleading prayer — and yes, peace.

It’s been a long time since someone close to me died. I had forgotten what it feels like.

Too often, when we discuss end-of-life issues in an ethics consult or some other formal “bioethics” setting, we do so in a detached, dispassionate, academic, objective, theoretical manner. We discuss Kant or Kilner, quote the latest article in the New England Journal of Medicine or Hastings Center Report, weigh the principles of autonomy and justice in our scales, and try to come to a logically defensible conclusion. This is of course important for clear thinking. But I wonder whether our “clear thinking” might not gain true clarity if we added to all of our cold calculations an experience, even a vicarious one, of the profound emotions involved in this, one of the most significant and mysterious of human experiences.

I realize Verdi might not be everybody’s cup of tea, and maybe not everyone would benefit from starting an ethics committee meeting or college lecture with a Confutatis or Libera me. But surely, even in our coldest scientific proceedings, there is an important place for the arts and humanities, for these modes of deeply human creativity that convey the experience and dignity of being human in a way that arguments never will.

 

(The CSO/Muti performance Thursday was webcast, and a high-quality stream is available for free here, at least for a while. Highly recommended.)