215. Memorandum from the White House Chief of Staff (Jordan) and the Special Assistant to the Secretary of State (Raphel) to President Carter and Secretary of State Vance1

We are waiting in New Orleans for a new plane to take us to Panama.2

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Based on our conversations today with Dr. DeBakey and with Ambassador Ambler Moss, we wanted to convey our thoughts to you prior to your breakfast meeting and discussions.

Shah’s Medical History and Present Condition: At the time of the Shah’s departure from the States for Panama, he was experiencing an enlarged spleen. As this was a condition he had experienced before, his doctors decided to defer surgery. Over the last several weeks, the condition of his spleen has deteriorated and his spleen has enlarged to the point that his doctors consider the operation both necessary and critical.

At the recommendation of his doctors, Dr. DeBakey was contacted and retained to perform the operation. The announcement of the selection of Dr. DeBakey infuriated and insulted the Panamanian doctors who have been caring for the Shah the several months he has been in Panama. Representatives of the Shah in New York made background statements to the press which said that the Panamanian doctors were not competent or qualified to perform the necessary surgery. This immediately surfaced in Panama in the media and prompted an emotional and irrational response by the doctors that DeBakey could not operate at the Panamanian hospital. Ironically, most of these same Panamanian doctors were trained in medical schools in the United States.

At any rate, Dr. DeBakey arrived in Panama to find a very unpleasant situation. He found the medical staff at the hospital—on whom he would have to depend during and after the operation—resentful of his presence and almost openly hostile to him. His immediate reaction was to say that he would withdraw from the case, as his only interest was in seeing that the Shah received proper medical attention.

From all that we know, the reaction of the doctors was spontaneous and genuine and not stimulated by the government. However, once they took a public position of being opposed to DeBakey doing the surgery, the government did not attempt to reverse it. After a cooling-off period which took the good efforts of Ambassador Moss, Dr. DeBakey and the key Panamanian doctor met to resolve their differences. The Panamanian doctor was embarrassed at the situation that had been created and pledged a more cooperative attitude in the future. It was agreed by both doctors that a cooling-off period was necessary, and that a delay of up to two weeks was medically tolerable for the Shah.

Realizing that he might very well have to operate in the Panama hospital ultimately, Dr. DeBakey went to great lengths to make peace with the doctors. But he left Panama shaken by his encounters with them and concerned about conducting the operation in such a hostile atmosphere. DeBakey told us that one of the Panamanian doctors has reported to him that he has been offered $1 million to kill the Shah. [Page 567]Dr. DeBakey said that he had operated in 30 different countries in very unusual circumstances, but that was the worst situation he had ever encountered. Some or all of this was conveyed to the Shah by DeBakey, and he quickly hardened against having the operation in Panama. This probably stimulated the latest initiative to go to Egypt for the operation.

Meeting with Dr. DeBakey: In talking with Dr. DeBakey, we laid out for him all of the concerns which we see. We told him that we shared his interest in seeing that the Shah received good medical treatment, and we had the additional responsibility of the lives of 53 Americans being held in Iran. We tried to probe as to what new conditions—improvements—would be required before he would be satisfied to conduct the operation in Panama.

He talked very frankly and insisted that his comments be treated in total confidence. I assured him they would be treated in confidence.

He said that the Shah is a very sick man and that his condition is fragile. He said that his principal concern about Panama was not a concern based on medical facilities, but on the larger questions of authority and attitude. He said that the operation itself was not difficult or particularly risky, but that complications often arose in the post-operative period that could be serious and fatal. He said that someone had to be in charge, and that he could not tolerate a situation in the operating room or during the post-operative period when a decision he had taken was undermined or reversed by well-meaning Panamanian doctors. He said that he could operate in a tent with less risk than in a situation where his authority was not clear and a general atmosphere of hostility existed which might prejudice the care given his patient.

We asked if assurances were given by the Panamanians as to his ultimate authority, would he be willing to do the operation in Panama. He said that he would do the operation in Panama if he had to, but, based on his experience there and the hostility directed toward him by the medical staff, he would not believe or accept assurances if given by the Panamanians.

He said that he thought the brief delay in the operation would create a situation in Panama which would permit him to conduct the operation there, but that his professional medical advice to the Shah would have to be that he would be better off to go to Egypt or the United States for the operation. We pressed him as to the degree of risk.

He said that the risk of death to the Shah in ideal medical circumstances was in the range of 5 percent. He said that if the operation was conducted in the Panamanian hospital under the present circumstances, the risk would increase to the range of 10 to 15 percent. We asked if there were steps we could take to diminish that risk, and he said that all we could do was to obtain assurances from the Panamanians that he could trust.

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His bottom line was and is that he is willing to perform the operation in Panama in partnership with the Panamanian doctors, but that his medical advice to the Shah would have to be that the surgery could be performed with less risk in some other country.

Options: As the Shah considers what to do, he has three basic options: for the operation to be performed in Panama (either in Paitilla or Gorgas), in Egypt, or in the United States. Each of the options carry heavy costs for us.

Panama—The Shah is extremely hesitant to have the operation performed in Panama and was traumatized by the events of last weekend when the operation was scratched. He has said he will continue following DeBakey’s advice, and DeBakey has told us that his medical advice will be to operate in Egypt or in the United States, not in Panama. We do not believe that any other Panama-related alternative, such as the use of a French medical team, will now be acceptable to the Shah. The second possibility in Panama is to operate at Gorgas Hospital. The Shah would most probably find this acceptable. It would also mean we are somewhat less exposed than we would be if he came to the States for the operation. On the negative side, Ambassador Moss believes there would be a very negative reaction from the Panamanians with a real possibility of demonstration and possible violence at Gorgas. Also, the Panamanians told us that they will not allow the Shah to remain in Panama after the operation. This may be a bluff and, faced with an embarrassing departure of the Shah from Panama, there is a slight chance of developing a better Panamanian attitude at Gorgas. Also, after three or four weeks, we would be faced with the strong possibility of having to take the Shah into the States after the operation. The main attraction of Gorgas is that it would buy us three or four weeks delay, would be somewhat less disruptive to our continued attempts to gain the release of the hostages, and there would be less of a chance that the militants would take action against our hostages.

Egypt—Ambassador Moss and we believe that the Shah is ready to contact Sadat this weekend and ask for permission to go to Egypt. We all agree that this would be highly detrimental to Sadat’s domestic and regional position and our own policy in the area. We assume that Sadat will stick to his invitation. If we are to avoid having the operation in Egypt, we should be prepared to hold out some alternatives to the Shah as early as tomorrow.

United States—The disadvantages of having the Shah return to the States for the operation are evident. Our overriding concern would have to be what actions might be taken against the hostages as a result of his entry. At a minimum, we have to accept the possibility of the hostages being held indefinitely, and we would have to contemplate the terrible thought of immediate violence being directed against them [Page 569]as a result of the Shah’s return to the States. On balance, in terms of our national interest, it is preferable to have the operation performed in the United States rather than Egypt.

Summary: The Shah has a terminal illness and is a dying man. Dr. Norman Rich, who accompanied us and who has worked with Dr. DeBakey and is an expert in this area, estimates that he has no more than one or two years to live. If you decide to allow the Shah to return to the United States for the operation on humanitarian grounds, I think it is important that he understand clearly the ramifications of his return to the States and accept some personal responsibility for a decision to return. Although we are not saying that this would work, we believe that if the Shah was confronted with the stark realities of the situation and the ramifications of each of the options, he might decide to ask Dr. DeBakey to perform the surgery in Panama.

We would suggest an approach to the Shah that is frank and acknowledge our willingness to receive him in the United States. We would use talking points along the following lines:

—The President understands that surgery may be necessary and is concerned that the surgery be conducted under conditions that are satisfactory both to yourself and to your doctors.

—If your doctors analyze the need for surgery to be both critical and pressing, we are willing to have you return to the United States for surgery. We are sure that you would want to know and understand our frank analysis of possible consequences of your return.

—We understand that another option is for surgery in Egypt. We believe that if the surgery were performed in Egypt it would have a very detrimental impact on Sadat’s internal position, which is already precarious, and will increase his isolation in the Islamic world. The President would strongly prefer that, if you are convinced the surgery cannot be performed in Panama, it should be done in the United States rather than Egypt. The President is confident that you share this personal concern for President Sadat and wanted you to have the benefit of our own analysis.

—You should realize that the President of the United States believes, at a minimum, that it would prolong the detention of the American hostages in Iran and increase the chances of some immediate harm coming to them.

—We understand that Dr. DeBakey will perform the surgery wherever you decide.

—We realize the conditions in Panama are not as good as they might be elsewhere. We know that this is a difficult decision for you to make. You and your family are justifiably concerned about the chances of the success of the operation. You are faced with a very hard [Page 570]choice of having to balance your legitimate personal concerns with humanitarian concerns that might emanate from a decision not to operate in Panama. The President wants you to know, with this background in mind, that the final choice is yours. We will respect and abide by any decision you make.

—If you decide to leave Panama for either Egypt or the United States, it will require at least several days of highly sensitive preparations and discussions. For that reason, we will go to great lengths to keep confidential even the possibility of your departure. Once you have made a final decision, we would ask for various reasons that it be kept in strict confidence until time for departure.

Final Thoughts: After your breakfast meeting, we would like to have your reaction to this proposal by telephone.3 If we decide to offer and the Shah exercises the option of returning to the United States, we should give the Iranians prior notice through our French lawyers. This might stimulate the government to take control of the hostages. It is certainly worth the risk. I would remind you that we have a commitment from the top elected official there to effect the transfer by the 25th.

(This memo was dictated in the middle of the night, so we apologize for not being lucid and coherent, but it represents our best thoughts and analysis.)

  1. Source: Carter Library, Office of the Chief of Staff, Jordan’s Confidential Files, Box 12. Secret.
  2. In his memoir, Jordan recalled that, after receiving intelligence that the Shah planned to leave Panama, Brzezinski said to him: “Hamilton, Panama and the Shah are your specialty. I’m in charge of current leaders and big countries—you’re in charge of former leaders and small countries.” Jordan then made plans to travel to Panama. (Jordan, Crisis, p. 199)
  3. No record of a telephone conversation has been found.