Leadership

Reflect, Then Decide

Making the right choices is the most important part of leadership. Every other element-from developing and communicating ideas to surrounding oneself with great people-relies on making good decisions.

One of the trickiest elements of decision-making is working out not what, but when. Regardless of how much time exists before a decision must be made, I never make up my mind until I have to.

Faced with any important decision, I always envision how each alternative will play out before I make it. During this process, I'm not afraid to change my mind a few times. Many are tempted to decide an issue simply to end the discomfort of indecision. However, the longer you have to make a decision, the more mature and well-reasoned that decision should be.

As explained in Chapter 2, I used the morning meeting as a way to drive decisions. Because I forced my top staff to see me every day, decisions couldn't be avoided. Some mayors tended to hide in the mayor's office, with a chief of staff or first deputy mayor shielding them. You'd have to talk to that person before the mayor, and the stand-in would know what issues the mayor didn't want to face.

The same is true in many large corporations. Instead of rolling up his sleeves and saying, "Okay, I'm here to make a decision," some CEOs hide behind a phalanx of vice presidents who protect them against the risk of making a bad decision.

Procrastination becomes a state of mind, and filters through the entire organization. But a readiness to make decisions has a positive effect. Without my even asking most of them to do so, my deputy mayors and commissioners implemented their own versions of my morning meeting, and so established their own willingness to hear problems, make decisions, and risk suggesting unpopular proposals.

A chief executive is often called upon to communicate directly to the public. Although it's best if that's handled by the leader himself, a CEO in the private sector who does not communicate well can get away with hiring someone to do it for him. In government, however, the chief executive is the public face, whether he likes it or not. As mayor, I was sometimes criticized for running too much of a one-man show. Actually, the opposite was true. My administration was structured around committees. It was extremely collegial-which is not to say we had no battles. But I always considered everybody's opinion before I made up my mind, and doing so actually sped the implementation of programs.

Here's an example. New York City's parks were a major focus of my administration. Nearly all my principal concerns-quality of life, economic redevelopment, child protection, even crime reduction-were enhanced by well-tended, safe, beautiful parks. During the eight years of my administration, New York City gained 2,038 acres of new parkland (by way of comparison, 372 acres were acquired during the four-year administration of my predecessor, and only 1,744 acres during the twelve years of the Koch administration). When I was sworn in, 69 percent of the parks were graded acceptably clean. When I left, the figure was 91 percent. We created dozens of parks in all five boroughs, including the Hudson River Park from Battery Park to 59th Street in Manhattan, the Brooklyn Bridge Park, which will eventually extend 1.3 miles along the East River waterfront, and the seven-mile Bronx River Greenway.

In 2001, I announced the renovation and renaming of the park on the Manhattan side of the East River to honor former New York City Mayor John Lindsay, who died in December 2000. The park needed some repairs because the retaining wall along the river was beginning to crumble. There were different views on how to accomplish this, so we met to sort it out.

The engineers issued a report saying we should close the park immediately. My Parks Commissioner, Henry Stern, said the engineers were exaggerating and that we could easily keep the park open for five to ten years before the wall began to sag. He felt that people who wanted to enjoy the park should at least have until the end of the summer, if not longer.

In many organizations a decision would have been deferred. That's the way it works when the model is designed to protect the chief executive. Other top executives will do anything to avoid a fight-they're reluctant to allow their staff to argue with them, or each other. The reluctant CEO would have asked everyone to write a memo, then they'd conduct more studies. By that time, action would happen by inaction-either people would be using the park in a dangerous way or it would have been shut down and no work would have been started.

That particular meeting was fairly contentious; but forcing everybody to meet got the cards on the table. And, once I felt enough information had been presented and all sides had been heard, I made a decision. That morning I decided that we'd shut the park and get the work started immediately, which would mean the repairs would take place during the winter months and be completed in time for people to use the park the following summer.

Decision-making would be easy if it were always a choice between good and evil or right and wrong. In the real world, leaders have to make decisions that are multidimensional, usually between two or more imperfect remedies, on criteria that encompass long-range goals and plausibility. In 1999, the contest for the Republican presidential nomination was gathering steam. Two men I knew and admire, both highly qualified to lead the country, were vying for the nomination. I had to make a choice.

John McCain has been a good friend for years. Because of what he endured as a prisoner of war for five and a half years in Hanoi, and all he has accomplished as a senator and man, he is a hero to me. The experience he went through can have one of two results-it can either crack you, or make you into a great man. In John's case, it was emphatically the latter. As I got to know him, I saw what a genuine person he was. In the months leading up to the campaign, we talked about his running for president.

I didn't know Governor George W. Bush as well. So I went to visit him in Austin to get to know him better and was impressed. By the summer of 1999 I concluded that he had a much better chance of beating Al Gore. For one, the Bush name unified the Republican Party right away. He went into the race with obvious support in two big, important states-Texas and Florida. I also felt close to his brother, Florida Governor Jeb Bush: I had campaigned for him, and he had helped me in the past. The way Governor Bush ran his reelection campaign in Texas in 1998 showed broad appeal and made strong inroads among Hispanic voters. I thought he could be a crossover candidate unlike any other the GOP could produce. Further, Bush had command of what would be the key issue in the 2000 campaign-education. He devoted his attention to it as governor, and had done a good job. The art of being successful in presidential campaigns is figuring out the theme that will captivate people. Too often, candidates try to run the last campaign over again, but that's a losing battle. In 1992, Bill Clinton capitalized on repetition of his "It's the economy, stupid" theme. I thought the approach in 2000 should be "It's education, stupid," and Bush owned that issue.

Most important, I found Governor Bush to be a person of real substance during the time I spent with him. I knew the media would underestimate him, just as they had Ronald Reagan. This would be particularly true of the Eastern media, because Governor Bush doesn't speak in a way that suits their biases. The Eastern media mistakes pretense for substance and polish for smarts. Their habit of dismissing those who don't press those buttons usually works to such a candidate's advantage. So although I was personally closer to John and perhaps would have supported him if he had had as good a chance of beating Vice President Gore, I told him that I was going to support the Governor-but that I would never say anything negative about him or participate in negative campaigning directed at him. Then I let George Bush know that he had my support. I told him I was a good friend of John McCain's, and explained why I had made my decision-that I thought he had a better chance of winning. I also told both men that if I could ever play any role in bringing them together, I would be happy to do so. In fact, Dick Cheney had not yet been mentioned as a vice-presidential candidate, and I thought Bush/McCain would be a terrific ticket.

Having made my decision, it was time to test it. As I began supporting Bush, some strain developed in my relationship with John. Whenever we talked, he would make half-teasing, half-zinging comments about my not supporting him. Then something happened that repaired that damage but created strain with the Bush camp. As the New York primary approached, there was a movement to keep McCain's name off the ballot. The state of New York has Byzantine rules about getting on its primary ballots-there hadn't been a contested Republican presidential primary in twenty-four years-and some in the state GOP sought to protect Bush by keeping John off the ballot. I didn't think that was fair, and some of Bush's supporters interpreted my saying so as evidence of hidden support for John. It wasn't. It was just a straight, honest opinion. Additionally, I was convinced that Bush would beat McCain in New York and that that would be a better way to win.

They finally relented and put McCain in the primary. Immediately after that, whoever was running Bush's campaign in New York started to criticize McCain for having voted against breast cancer research. That's a big issue in Nassau and Suffolk counties, because the disease appears to affect women on Long Island disproportionately. I was asked to join in the criticism, which would have stung because I was at the time dealing with cancer myself.

I refused. First, the reason he had voted in the way they were referring to was that it was against part of a big Christmas-tree bill with a bunch of other items in it, so this vote had more to do with John's usual stance against overloaded legislation. I also thought negative campaigning was unnecessary. Bush was going to beat John McCain in New York, and there was no need for him to come out of it with a black eye for attacking a guy who had become a darling to the media, as well as to the independent voter, the exact voter Bush was going to need. John called to thank me. "I think you should be supporting me instead of Bush," he told me, "but I really respect you for not joining in the negative campaigning." For a while some of the Bush people were suspicious of me and whispered that my support might not be as strong as they wanted.

Afterward, I worked hard for Bush, and I think in the end his people respected me for my decisions. I know John did. It was like walking a tightrope, but it was an honest tightrope. Governor Bush went on to win the primary in decisive fashion.

BATTLING CANCER

One of the toughest series of decisions I ever had to make occurred during several extraordinary weeks in the spring of 2000. Decision-making weaves together the threads of all the rules for being a leader, so I'm going to explain at some length the interconnected decisions I made during that time. As some were literally life-or-death matters, and others had time limits associated with them, this volatile period provides an ideal examination of how I make decisions.

On Wednesday, April 26, Dr. Alexander Kirschenbaum of Mt. Sinai Hospital called me and said the five words nobody wants to hear: "Your biopsy results are positive." For a second, that sounded all right: I tend to associate "positive" with good news. Then the weight of it hit me. I had prostate cancer.

Nineteen years earlier, my father had died of the disease, at 73. This form of cancer kills about 37,000 Americans a year, so regular blood screenings for prostate specific antigens (PSA) are recommended for any man over 45. Those at higher risk, such as African Americans or those with relatives who have had the disease, should seek annual tests after 40.

In my case, early detection came as the result of a general physical. I have a degenerating vertebra at the top of my spine that bothers me about every five years. It was acting up-I was campaigning hard and feeling tired. On Thursday, April 6, I went for a physical and was given a PSA test and a digital rectal exam while I was there. I had no symptoms, so it was not as though my doctor suspected anything. In fact, he said, "Before I examined you, I expected you to show some high blood pressure, since you're under a lot of tension. It's remarkable, but your blood pressure's fine, and your prostate feels normal. Everything looks great."

The next day I was driving to a fundraiser at the Binghamton Country Club, in western New York, about three hours west of the city. I got a call on my cell phone from the doctor, who said my PSA test was in the questionable zone-high, but not very, and most likely nothing to worry about. He was leaving on vacation for a week, and said that he would arrange for more detailed tests with a urologist when he returned.

Judith was in the car with me. At that point, she was working for Bristol-Myers Squibb, the pharmaceuticals corporation, and knew just about every doctor in New York. Quietly, I explained what I had been told. There were others in the car and I didn't want anyone to know. I said, "Judith, we'll be back late tonight, after midnight, and I want to see a doctor tomorrow." She reminded me that the next day would be a Saturday and I said, "That's okay. I want to get started right now dealing with this. I don't want to wait."

Judith phoned a good friend of hers, Burt Meyers, an expert in infectious disease at Mt. Sinai Hospital. I knew him, too and he ended up being an advisor after the attacks on the World Trade Center. I told Judith to ask Burt to recommend a urologist and said, "It's okay to tell him what this is about." The next morning I went to see Dr. Kirschenbaum and he put me on ten days of Cipro, the drug that was to become famous during the anthrax scare. I asked, "Alex, can't we do the biopsy right now and find out?" He said, "No, because a modest elevation like this is often caused by an infection. The Cipro will do away with any infection." PSA can be driven up by many things, even an irritation of the prostate gland, so an elevation doesn't necessarily indicate cancer. After ten days on Cipro, I went back for another PSA test. A lower reading would indicate that there was an infection and not possible prostate cancer.

I remember exactly where I was when Dr. Kirschenbaum called me back with the results. I had gone to an evening Mass with Judith and Tony Carbonetti for Holy Thursday at St. Vincent Ferrer Church on Lexington Avenue, then on to Gino's restaurant just down the street. As we were eating dinner, my cell phone rang. My PSA was still high.

Judith took over with Dr. Kirschenbaum on the phone, getting the information I needed. By this time she had already done a lot of research about prostate cancer on the Internet, about percentages and chances. I had begun thinking about my treatment options, in case it was cancer. I scheduled a biopsy for early in the morning on Tuesday, April 25, right after Easter. Judith had told me that parts of the cancer can sometimes be missed in a biopsy, so I asked them to take the maximum number of samples. When we arrived at Mt. Sinai, there was a reporter outside, who asked me what I was doing there. I have no idea if he just happened to be hanging out there or if someone tipped him off to my arrival.

On April 26, at four p.m., I was sitting in my office at City Hall when Dr. Kirschenbaum telephoned with the fateful five words. After explaining some of the issues, he asked whether I'd prefer to meet him in person. I certainly would have, but I was reluctant to go to his office because the press was already calling my office to ask why I'd gotten a biopsy. Dr. Kirschenbaum suggested meeting me at Gracie Mansion. At about six p.m., he came over and went through a description of the biopsy findings. He did a drawing of the prostate and showed me that the cancer was found in one area but not the other, reviewed my treatment options, then explained how I should pursue a decision.

My head was swimming, but there was no time to digest what I was being told. I had to cut our meeting short to greet the Consular Corps. I found myself making a speech and posing for a hundred photos with diplomats just outside the room in which I had learned that a deadly cancer, the same disease that had killed my father, had been found in me. I returned to talk to Dr. Kirschenbaum some more and he told me he needed to take some additional tests.

This was the most frightening part, because it would determine whether the cancer had spread beyond my prostate. The doctor told me, "From what I can see and feel, I'm virtually certain that it hasn't."

"What does 'virtually certain' mean?" I asked.

He said, "Well, let's say there's a one percent chance."

The minute I heard that, I thought, "How do I know I'm not the one percent?" On the day that you're told you have cancer, you don't feel like a lucky man. I asked him to schedule the tests for the very next day.

I couldn't spend too much time feeling sorry for myself. There had been the photographs to take, the Consular Corps speech to give, then a preview of a play that I had promised to attend. In a way, resolving to do those things minutes after learning I had cancer was the first "decision" I made. I wasn't going to let the disease take over.

At the time, I had been gearing up for months to run for the seat being vacated by Senator Daniel Patrick Moynihan. I had raised considerable funds and was looking forward to what was shaping up to be an exciting race against Hillary Clinton. At the same time, my personal life was entering what can be described with some understatement as an "interesting" phase.

Any prostate cancer patient faces one immediate decision regarding treatment. There are three basic options: surgery, radiation, and hormone therapy. Surgery, known as "radical prostatectomy," removes the entire prostate. Those who choose radiation face three additional options. They can blast the area with external-beam radiation, target the precise area of the tumor with proton radiation, or implant radioactive seeds. Some men also choose hormone treatments to slow the production of testosterone. This can be used as a stand-alone method or in conjunction with the other treatments.

Each method has its pros and cons, with various side effects and levels of effectiveness. Many factors must be considered, such as the size and aggressiveness of the tumor, and the age, lifestyle, and overall health of the patient. Many prostate cancer patients find the decision on treatment agonizing.

Contemplating a decision about dropping out of the race for the Senate was clouding my decision about how to deal with cancer. Without consciously realizing it, I was trying to evaluate my treatment options with one eye on the Senate race. I'd catch myself thinking, "Well, if I get the surgery and am out for six weeks, then I'll be back by September. I'll spend July and August recuperating, and I can't do any fundraising, and I'll miss this event and that debate."

I would start thinking about what would happen if I didn't recuperate in time. I was concerned that I couldn't campaign 18 hours a day. In a campaign, my basic style was to wear down my opponent, and I realized I would not be able to do that. And then, of course, all the projections about side effects were based on percentages. When dealing with the side effects, some people recuperate easily. Others take months, held back by urinary problems, fatigue, sometimes simply by the pain involved. Suppose I fell into that category?

Radiation treatment had odds and side effects of its own. These were likely to limit me. Even though I was leaning toward radiation over surgery, I started thinking, "Well, maybe I can stay on Lupron longer and delay whatever treatment I choose until after the election." The doctors were telling me I didn't need to take immediate action, but when I asked whether it was advisable to put treatment off for six months, they flat-out said I shouldn't.

There was a ridiculous amount of media speculation at the time, focusing on what treatment I'd choose and how it would affect my run for the Senate. There was a soap opera quality to the coverage, and it became disturbingly easy to forget that it was a man's life being discussed so cavalierly. I quickly stopped reading it. First of all, a great deal of the coverage was wrong. Reporters were talking about me to doctors I'd never even met. Second, the saturation coverage was becoming chaotic, because of the national interest in the Senate race. Reporters tried to follow me to Baltimore, where I was consulting with doctors at Johns Hopkins. Others tried to get my health reimbursement records to deduce which specialists I was seeing. People were calling hospitals all over the city to see whether I'd spoken to them. Television networks wanted to follow me to my treatments and asked if I'd be willing to have a camera come with me to my MRI and other extremely private moments-even a digital rectal examination. Although I was accustomed to being in a fishbowl, the intensity of the scrutiny was really beginning to affect my judgment, and my ability to focus on the medical options.

I had a gnawing feeling that it was wrong to allow the Senate race, as important as I thought it was, to affect decisions about my health. I took advice on the topic from all sides-from people who desperately hoped to see me outpoll Hillary Clinton to those who cared only about my well-being. The advice that rang the strongest was from Ken Caruso, who remained a close friend after having served as an assistant when I was U.S. Attorney. Often, when I seek multiple points of view, one person's take comes to represent the position that I end up selecting. In this case, it was Ken who crystallized my thinking.

He had been away in England, so he wasn't involved in the daily soul-searching that I was doing. He came to visit me at City Hall on May 18 and didn't hesitate to set out his opinion. "I'm just going to give you a perspective from somebody who's been reading about this in the newspapers from far away," he said. "I don't care if you're a senator or a mayor or anything else. You can't do anything unless you live, and are healthy. You're my friend. Put your health first." I decided to make my health my main concern, and to do so with a clear head I couldn't run for the Senate.

As soon as I agreed with that priority, other decisions fell into place. My first decision was that I would include hormones in my treatment.

Just making this decision provided a great degree of psychological peace. Secure in that knowledge, I could turn my attention to the other decisions. I had already begun taking a pill called Casodex, which began the process of reducing the testosterone in my body by shutting down the valve that led to the prostate. This served as a precursor to my first Lupron shot, since it ensured that the prostate wouldn't be flooded with the Lupron. The monthly injection of Lupron shrinks the prostate by shutting down the production of testosterone, the principal male hormone. That's valuable because when you're first diagnosed, you think the cancer is taking over your entire body. Knowing that the growth has been stopped allows the patient to make decisions about future treatment with a clearer mind-you don't feel as if the cancer cells are subdividing and attacking every second that you spend considering other treatment options. (Lupron alone is not a viable treatment for most prostate cancer patients. The majority of researchers view it as a temporary cure, so except for much older men it is generally not used as a single treatment.) I was leaning toward radiation, but was still considering surgery-I'd say it was 60/40. But because I prefer not to make decisions until I have to, I decided that I would take the Lupron so that I didn't have to rush to judgment. Since radiation takes a few months to prepare for anyway, taking the Lupron would be that preparation for me, if I chose that option. And if I wanted to go into reverse and have surgery in July or August, the Lupron wouldn't be necessary, but wouldn't hurt.

On the morning of Friday, May 19, without telling anyone except Judith, I went to get the Lupron injection-a deep shot into the muscle of the backside. Later that day, following the literal and figurative shot in the ass, I announced that I was not going to run for the Senate.

Once I was on the Lupron, it took a while to be comfortable choosing my exact course of treatment. But now, with the white light of the Senate race no longer blinding me, I could make the decision more privately-not totally so, but with a modicum of solitude. During the course of the injections, my prostate was examined several times to determine if the Lupron was continuing to reduce the size of it. Once it had been shrunk as much as it could-which took three months-it was time for the next phase.

To clear my head during the period before I'd be ready for radiation, I took a month off from my immersion in the study of prostate cancer treatments. I wouldn't say I emerged "rejuvenated," but I was as refreshed as a pre-cancer-treatment, Lupron-taking mayor of a major city can be. Judith and I went back to several of the doctors and reinterviewed them. We discussed surgery and the various radiation options-internal seeds, external proton blasts, some combination of both. I spoke to Dr. John Blasko, who along with Dr. Haakon Ragde had developed the whole non-surgical transperineal seed implantation treatment in Seattle. I met Christine Jacobs, the CEO of Theragenics Corporation, which manufactures the seeds. She in turn put me in contact with specialists all over the country. When I rang Dr. Kirschenbaum after speaking to all these doctors, he said, "Tell me everyone you saw and I'll tell you which course of treatment each doctor advised." I mentioned a dozen names and, sure enough, he nailed every single physician's recommendation. Having considered all the options, I decided on using both seeds and external radiation, because I wanted to make sure I did everything I could to kill whatever cancer cells lingered there.

Ultimately, that option suited me better than surgery, which, while it removes the cancer from the prostate, doesn't guarantee that other cells may not be lurking just outside the treated area. There was a risk that I would have had to return for radiation later, and they couldn't have given me as much of that-once the prostate is missing, the amount of radiation has to be reduced. So I opted for putting the seeds inside the prostate, to provide the maximum likelihood that the cancer was killed.

I selected Dr. Richard Stock at Mt. Sinai to do the implantation. That choice illustrates an interesting point about management. Dr. Stock was younger than most of the other doctors I'd seen, but I chose him because I find that the generation that succeeds the originators of an idea will often take it to a new level, to make its mark. In this case, the originators of seed implantation would do a scan of the prostate and determine where to place the seeds before the surgery. The next generation, however, was looking to plant the seeds not entirely from a previously made scan but in real time, reacting to what they found when they went into the prostate. It reminded me of how each of my Police Commissioners improved on the innovations created by his predecessor.

I decided that after the implantation I'd supplement the seeds with twenty-five external radiation treatments-five a week, for five weeks-both to continue to kill the cancer cells inside the prostate and to provide a perimeter of a centimeter or two beyond where the cancer was found.

Early on the morning of September 15, 2000, I arrived at Mt. Sinai Hospital for surgery. In the operating room were Dr. Stock, Dr. Kirschenbaum, and a host of assistants and nurses. I shook hands with everyone. Considering the gravity of the situation, it felt surreally like a campaign. Next, I was given a preoperative dose of sedative and a spinal anesthesia. With all these young people in the room, I was slightly self-conscious to be exposed like that. As the sedative started to take effect, I lay down, and as I entered a half-sleep saw a huge television being wheeled in. There had been so much speculation surrounding my treatment that it had even been suggested that I allow the procedure to be broadcast, a notion I of course rejected. Seeing that television, I thought, "Oh no, I'm going to be in the altogether on New York 1-someone sold me out!" Just as I was finally drifting off, I recalled that the television screen was used to do the surgery. Relieved, I faded into oblivion. Two hours later, Dr. Stock woke me to tell me the operation had gone perfectly.

I've made business, professional, and political decisions this way all my life. It was similar to deciding how to sell the city's OTB operation, or how to run the coal company I was assigned to manage when I was in private law practice. In each case, I tried to construct the freedom and the time to make the most informed decision possible.

At the same time, I was ready to act on much less notice, had that been necessary. If the doctor had told me on that fateful Wednesday that I had cancer that was spreading rapidly and recommended that I have surgery the next day, then that's what I would have done. I wouldn't have delayed. But this was a different kind of decision. Every doctor assured me, and I knew from my own reading, that mine was a slow-moving cancer. Even had I done nothing, I'd have had some time to decide without worsening my prognosis.

Being mayor actually helped me get through these months, because I had responsibilities-still had people who depended on me. It also got me out of my own head and kept me from wallowing. I believe strongly that you never should be dishonest with yourself. You face your fear. The other benefit about my being open about having cancer was that the support I received was a source of great strength. Many people diagnosed with cancer feel that they have to hide it-that it will feel less real if no one knows about it, or that their employer will hold it against them, or that their friends will pity them. In fact, the fear gets worse by being hidden. If you can say, "I'm afraid to give that speech," "I'm afraid to make that decision," "I'm afraid to deal with cancer," you can start dealing with it. In my case, I relied on people close to me. Judith Nathan and Denny Young were enormously helpful. Beth Petrone, Kate Anson, Sunny Mindel, Tony Carbonetti, and Manny Papir (Deputy Chief of Staff) stood by me, at work and personally. The police officers on my security detail also helped-they're the ones who went with me at seven a.m. for my radiation. And I was grateful for the kind words from thousands of people who called or wrote me. In fact, I was in the car on 86th Street, turning onto East End Avenue, when Hillary Clinton called to offer sympathy. Many people who contacted me had dealt with prostate cancer and had advice-including several well-known figures who had never publicly disclosed having had the disease.

No matter how open one is about a life-threatening illness, ultimately you face it alone. People can help you deal with the symptoms, sympathize with the effects of the treatment, but no matter how much support you have, there are still nights when you suddenly wake up, frightened. The way I face fear is by feeling it, acknowledging I'm feeling it, and then assessing my options. Prostate cancer is a frightening disease. But at least there are options for dealing with it.

Although I was honest about what I was going through, there were many private details that I kept to myself. One's sense of privacy and sensitivity to how others will receive the news dictate how much you should share. Some of my staff must have known what was happening, but I didn't talk about it. However, I do recall one time when I was on my way to a campaign event for New York State Senator Guy J. Velella up in the Bronx. The press was attacking him for being under investigation by the Manhattan District Attorney, and he needed me to stand by him. I was feeling sick throughout that day, and as soon as I got in the van I knew I shouldn't have. About three miles later, we pulled over so I could jump out of the car and I got sick all over the street. I was very embarrassed. But I washed up as best as I could and went on to the event. We rode around in a truck, and as I waved to the crowd I was sure I was going to faint. But having to perform-being needed-got me through. Later on, I thought of my fight with cancer as basic training for September 11. I tried to keep a stiff upper lip, but there were other times during which the aftereffects were difficult. Oddly enough, there was so little pain during the first two weeks that I began to wonder if perhaps the seeds weren't powerful enough. I knew from my research that there was supposed to be a burning sensation, but I barely felt anything. I called Dr. Stock to let him know, and he told me to give it a few more days. He was right.

On October 9, 2000, I marched in the Columbus Day parade with Senator McCain, and Representative Rick Lazio, who had taken my place in the Senate race. Stopping at a diner, I ducked into the men's room and was in such pain I could barely stand. I was afraid I would not be able to march in the parade. I hadn't taken a painkiller, but I knew I'd never last through the parade without something. I had been prescribed Vicodin. So I got it out of my bag, split the tablet in two, and swallowed half a Vicodin. Five minutes later, the pain was gone, and I was able to march.

Afterward, I went with John McCain and his staff to Little Italy for lunch. I drank a half bottle of wine, forgetting that I'd had the Vicodin, and soon enough we were singing away. What you learn from John McCain-and I'm sure this comes from his confronting death-is that you have to enjoy life while you can. I was determined to do the same.

I thought about my heroes and how they had handled illness or disability, at least when they were in public. When I did actually sit down and unburden myself about the fear and the worry, I turned to Judith. She was the one who took care of me the most. The first Yankees game Judith and I attended together was July 18, 1999. You probably already guessed she was a Yankee fan before we met, and the fact that David Cone pitched a perfect game was a harbinger of things to come. When Montreal shortstop Orlando Cabrera made the 27th out, I went totally nuts. At the ballpark, I happen to eat peanuts with the shells still on. It says a lot about Judith that she stuck with me after observing this controversial preference. With the cancer diagnosis less than a year later, I realized just how much everyone needs a partner to get through something like this. I don't know how I would have done it without her.

In addition to her compassion, Judith understands medicine. She got on the Internet, called her physician contacts for recommendations and advice, and analyzed the different medications. She accompanied me to virtually every doctor's appointment, and would go through the anatomical drawings and share her perspective. She would ask questions I wouldn't have thought of, and sometimes afterward I'd have her call the doctor because she'd understand the issues much better than I could. She accumulated a wad of notes about an inch thick, and would be my sounding board for all we learned. She helped figure out the changes in my diet (repeat after me: cooked tomatoes = lycopene, an antioxidant that researchers think may help prevent prostate and other cancers), and the vitamin and supplement regimen that I continue to take to prevent a return of the cancer.

All this helped tremendously. It also underlines the way I make my decisions-taking as much time as I can to consider as many angles as possible. A decisive leader can sometimes appear as though he never questions what his next move should be. Faced with tough decisions, I sometimes endure excruciating periods of doubt and soul-searching and, as I said, I always try to play out the results of each alternative. However, once I make the decision I move forward. Something clicks, and all my energies are applied to ensuring the decision works rather than fretting over whether it was the right one.

Today I derive a great deal of satisfaction in helping others with cancer, particularly with prostate cancer. I keep up on the research, and find it gratifying to give someone substantive information on how best to prevent, cure, or reverse the course of the disease. I can advise on a process of decision-making that takes as many of the factors into account as possible-odds of survival, severity of side effects, the probable consequences for one's family.

It helps to hold on to your sense of humor. Prostate cancer is specifically a man's disease. Because of the part of the anatomy it afflicts, and even the nature of the testing to see if one's got it, there's a natural tendency to make jokes. There's a blood test, which looks for an abnormally high number of prostate specific antigens, and there's a digital rectal exam, which is exactly what it sounds like. On the day I rang the opening bell at the New York Stock Exchange to launch a national prostate cancer awareness campaign, my Chief of Staff, Tony Carbonetti, let me know what he thought of the second testing method: "There's a tattoo on my rear end that says, 'Exit Only.'"

No matter what, people are frightened when they learn they have cancer. It's a daunting disease, and it's okay to be afraid-to wonder, "Why me?" But what's not okay is to do what so many men do and avoid being examined because they don't want to know.

Cancer is a particularly insidious disease. Because the cells in your own body are turning against you, it feels like a betrayal from within. Living in the world involves a certain degree of unavoidable risk. Anyone can be run over by a car or struck by lightning. But if you talk to enough cancer patients-and that's one of the best things someone diagnosed with cancer can do-you'll see that the temptation to avoid confronting it is nearly overwhelming. As with any big decision, especially one of life and death, you have to resist that temptation.

The feeling of betrayal that accompanies cancer expresses itself in a variety of ways. Every little ache and pain conjures a worst-case scenario. On the Sunday afternoon after the biopsy, I was with my son, Andrew, at Harbor Links Golf Course. I was playing particularly well (and that is rare) and we had reached about the fourth or fifth hole when I started to feel a pain in my back. I became convinced that the cancer had spread. Then I felt some pain in my fingers, and was sure that it was the cancer again. I started to wonder if I was going a little crazy. That's one of the reasons it's so important to keep in touch with others going through the same thing.

Five days after I was diagnosed, Howard Safir, my friend of twenty years, received the same news: prostate cancer. We spent a lot of time discussing our different options. I talked to his doctors, he talked to mine, and we compared side effects. Howard told me that shortly after his diagnosis, his toe started to hurt. After staying up all night from both the pain and the worry that the cancer was spreading, he went for an examination first thing the next morning. His doctor laughed, and told him, "Howard, if the cancer had spread to your toe, you wouldn't be standing there." It turned out to be nothing, and a day later the pain disappeared.

Relying on the companionship of others who have experienced it is critical as you put your life into perspective. I remember one of my weekly police meetings. I always sat in one of the red armchairs and Howard sat in the chair to my left. I'm looking at him and he's looking at me and we're both sweating. I realized we were having hot flashes together, and nobody else knew it. About two to three weeks after you begin the Lupron treatments, you experience these two- to four-minute sweating spells. Although the doctor tells you to expect them, the first few hot flashes really surprise you. Then, after a while, it's annoying, but you get used to it. For many reasons, my life was very different following my battle. Even more than any of the obvious changes, it left me with the philosophical perspective that comes from considering one's mortality. I honed my ability to compartmentalize the challenges I faced: the cancer diagnosis, the Senate race, the dissolution of my marriage, and-P.S.-I was also mayor of a vast and complicated city.

Just when I'd find myself sinking into self-pity, somebody would rush into the office to tell me a police officer or a firefighter had been injured in a building collapse or other life-threatening event. This would not only give me instant perspective, but focused me on whatever emergency had occurred. I canceled very few functions and appearances, and kept a work schedule every day, even if it needed to be abbreviated for the nap or two I had to take.

BE READY TO PULL THE TRIGGER WHEN TIME IS SHORT

Leaders must find a balance between speed and deliberation. One facet of making decisions involves knowing how to act when there's not much time to deliberate. In 1986, I was to try the Parking Violations Bureau case, one of the most important municipal corruption trials in the history of New York City. On my first day in court, the defense made a motion to change venue out of New York City, ostensibly because the defendants-politicians and bureaucrats-could not get a fair hearing before local jurors. They proposed several locations, such as Buffalo and Hartford. My assistants wanted to discuss among ourselves the merits of all the possible venues. I didn't. Even as they started conferring, I stood up and told the judge, "Your Honor, I agree. Let's change venue. It will remove any question of taint in the case."

My assistants were surprised, but my instinct told me that New York City-especially Manhattan, where this case was to be tried-was probably the toughest place to win a conviction. It's the greatest city in the world, but with eight million people it also has more screwballs than anywhere else. There's also a natural sympathy among jurors, however misguided, toward men whose names they've known for years. One has to remember that even notorious Gambino crime family boss John Gotti was acquitted twice by New York City juries.

The case was eventually tried in New Haven, Connecticut, with a jury from Hartford. As soon as the defense made their motions I realized why they were so eager to switch venues. Their counsel's strategy was dominated by the political sensibilities of the defendants, who took polls about everything. They determined the percentage of New Yorkers who had heard about the case, and the percentage who had already made up their minds. They had even taken polls about me, measuring my standing among New Yorkers.

What they failed to realize was that all that was needed to find an acceptable jury was that 10 or 20 percent of eligible jurors who did not know about the case and had not formed a conclusion. In New York City, that percentage is a lot of people, and there's a good chance that one of those screwballs would be selected. If you're the defense, all you need for a hung jury is one true contrarian-and you're likelier to find him (or her) in New York than in New Haven.

I realized that the defendants were approaching the case as though it were a political campaign. It was a strategic error. A trial lawyer picking a jury seldom identifies that one person who has gone through life not being able to agree with anybody. John Gross, who had been my colleague in the U.S. Attorney's office and my law partner at Anderson Kill, once tried a police corruption case where one juror would literally run to the men's room every time they went to deliberate, and refuse to come out. The judge had no option but to declare a hung jury. A second jury convicted on all counts after reasonable deliberation.

When I heard the alternate cities proposed by the defense, instinct told me each would be safer for us than New York. Agreeing to the defense motion before they had a chance to retract the offer helped us win a conviction.

The need for quick decisions, of course, is strongest in times of crisis. People are afraid and uncertain, and need to feel that someone is in charge. While the city was still coping with the aftermath of the attacks, anthrax spores were mailed to Tom Brokaw and other prominent media and political figures. The last thing New York needed was another reason to panic. Immediately, I made the decision that mail-openers were not going to be seen on television in the hazmat moon suits that were becoming increasingly common. That would have exaggerated the response. That's also why I went to the scenes of reported anthrax.

Even though leaders should take as much time as available to make decisions, the process of making the decision should begin immediately. If a decision is due in five days, the time to start researching and considering the matter is now, not four days on.

I was 26 when I became an assistant U.S. Attorney. I had a mustache-it was 1970. My then boss, Mike Seymour, would implore his AUSAs to "just do it." (This was many years before Nike used such advice as a slogan.) He always erred on the side of getting things done, and told us that if we pursued a course that always preferred action to hesitation we would be better lawyers, better people, and better everything else.

That's the precept I used as mayor. When something came up, we'd begin addressing it quickly, even as we debated and argued the best solution. I think that approach was one of the factors that gave the city a degree of confidence in its leadership. Sometimes, people just want to see issues being addressed, even if they don't always agree with the result. That's one of the reasons I held daily press conferences. Some told me that this allowed too many opportunities for controversy or for detractors, but I felt that when issues arose in the city it was vital to show that someone was at the helm.

USE CREATIVE TENSION

The fur could fly at some of the meetings of my top staff. I find debates enormously helpful, and would create them specifically so that I could hear more views on just about everything. I always make a better decision if I hear three or four different views. If those advocating those viewpoints do so forcefully and with passion, all the better.

You cannot generate heartfelt debate unless the participants believe that the outcome is not predetermined. If your staff knows that you'll defer to the higher-ranking person's opinion or choose the idea pitched by whoever's known you longer, they'll never develop their case to the degree you require.

City Hall Park, near the southern tip of Manhattan, dates back to the late 1600s and provides a magnificent nine acres of green space amid the world's most densely packed real estate. Unfortunately, the park began to feel the effects of neglect in the early twentieth century, as plans to repair it hit one snag after another. It even lost its centerpiece fountain, which in 1920 was shipped to Crotona Park in the Bronx. In my 1998 State of the City speech, I promised to restore the park to its former glory.

This involved a major renovation of more than $10 milllion. Not surprisingly, different members of my administration had different ideas for it. The Parks Department answered to Deputy Mayor Rudy Washington, and wanted to do it one way, while the Economic Development Corporation and others wanted to do it another. Everyone started taking sides, and it soon became clear that many opposed Rudy's plan. Further, they all tried the old trick of trying to get me alone to endorse one version or the other. I wasn't having it. I let them fight it out, and eventually decided that Rudy's was the way to go. People were upset, and I'd say the majority of my administration was surprised at what I chose. But in 1999 we reopened the park and it was better than ever. We even brought back the fountain.

One might suppose that the attacks on the World Trade Center would turn a staff of opinionated, habitual arguers into meek yes-men. Not so. By late September 2001, our morning meetings, taking place on Pier 92 (in a tiny room at a table covered with plates of bacon and sausage that, up till then, my staff wouldn't bring to a meeting in deference to my cancer-recovery diet), began to resemble the spirited intellectual street fights of the previous seven and a half years.

One of a hundred examples that came up regarded the flow of traffic in Lower Manhattan. To accommodate the heavy equipment working at Ground Zero and the tons of debris going out, the Holland Tunnel was entirely closed to regular traffic. The extra security at the other entrances to Manhattan, the roads destroyed and closed near the disaster site, and the destruction of the PATH train to the World Trade Center all combined to make traffic a nightmare. On September 26, we had it out. The idea of forbidding cars with only one occupant from six a.m. to noon had been championed by Iris Weinshall, the Commissioner of Transportation. Joe Lhota seconded: "We have to do this. Traffic is snarled so bad that even the emergency vehicles are having a tough time."

Deputy Mayor Tony Coles disagreed: "I'm skeptical of HOV [high-occupancy vehicle] rules. There are other ways to discourage traffic, such as promoting the trains and subways."

Larry Levy chimed in, "Forbidding any cars says, 'You can't come.'"

Bernie Kerik added, "The restrictions send a mixed message. We're telling everybody they gotta come back to the city, get back to normalcy. Then, on the other hand, don't come back unless you have more than one person in the car."

Lhota fired back, "You've got to live in an outer borough to understand this. Your thinking is upside down here. Traffic's backed up to Suffolk County. The state troopers are literally getting under the cars with mirrors-it's taking thirty seconds per car. Iris gave me the exact number today. Between six a.m. and noon, sixty-five percent of the cars have one driver."

John Dyson, who had been a deputy mayor and was at this point looking at the city's economy in the wake of the attacks, sided with those opposing the restrictions: "Joe, you're going to strangle the economy of the city if you do restrictions." Lhota retorted, "But subway use is down. We're actually seeing an increase in the number of cars."

Dyson: "Think about why. People remember Tokyo and sarin gas in the subways. You have to deal with what's going on in people's heads."

Coles: "Barring cars is really regressive. We should do incentives and other things, but it sends the wrong signal if we prevent anyone from entering."

I weighed in for the first time: "We've done such good work getting out the get-back-to-normal message over the last two weeks that we've almost fooled ourselves into not remembering that we are in an emergency. The Attorney General said we're in 'clear and present danger.' That's not code, that's plain as day. There's going to be anticipation as the President prepares to fight in Afghanistan. And then there's going to come a time when we actually strike. Both of those are points at which there could easily be attacks directed at the bridges and tunnels. That would be easier to handle with fewer cars."

Joe Rose, the city's chairman of the Planning Commission, added, "There are other mechanisms available, like congestion pricing" [raising the cost of entering during "peak" hours and discounting other times].

Lhota: "There are alternative ways into the city, too. Let's get the ferry system going better, and we might actually make the waterways an unintended third-party beneficiary."

I wrapped it up. "There's no perfect solution. If you don't do the restrictions, it's a traffic disaster and no one wants to come into the city. If you do the restrictions, you discourage certain people from coming, and you may still have a traffic disaster. Let's reassess this after we get the morning report from Iris. But for now, I'm in favor of trying her idea out for a week and seeing how it works. I don't think it's so awful to remind people we're in an emergency-we are."

The restrictions turned out to be successful in reducing traffic, while not proving overly onerous to all but a few commuters. People carpooled and made better use of public transport. As Joe Lhota had suggested, the ferry system did indeed pick up a lot of the slack and perhaps even reached the critical mass it needed to become a permanent option. As the crisis abated, so did the hours of restriction.

Sometimes the best way to stimulate the debate you need to make an informed decision is to take a step back. During the Cuban Missile Crisis, President Kennedy received some unconventional advice from his brother: leave the room. Bobby Kennedy advised the President that his aides had begun telling him what they thought he wanted to hear. Matters became so tense that each member of Kennedy's staff was afraid to back a decision for or against nuclear war in his presence. No one wanted to be accused of wrongly advocating getting tough or making concessions, of being too strong or too weak. President Kennedy left the room.

I did the same thing at times. During the campaigns, for example, I realized that we often got more out of the morning meetings when I wasn't there. Those present were more willing to say that the candidate-me-had screwed up the previous night, that I'd looked stupid on television or had handled a question badly. So I stayed away, and had Peter Powers or David Garth summarize the results for me.

HEAR PEOPLE OUT

Once you've made a decision, you must stick to it; but up until that point make it clear that you'll entertain changing your mind even on subjects that seem cut and dried.

When I became mayor, the current and next-year budget gaps made me determined to reduce city spending, for the first time since 1981, but I didn't want to repeat the mistakes made during the infamous fiscal crisis of the 1970s. So two areas were immediately off the table for spending cuts. I refused to make major reductions to the capital construction budget. When the city had made that error in the past, it had cost many times more to repair the basic infrastructure once it broke down than it would have had the city kept on top of the roads and bridges all along. The second area was the Police Department. The city was being destroyed by crime. Not only was I unwilling to cut the budget of the NYPD, I knew I would be adding to it. In addition to those two areas, the percentage of the city's budget devoted to the public schools was established by a state law that required the city to give the school system a fixed percentage of the budget each year. I might be able to spend what I wanted overall, but I couldn't alter the portion that went to the schools. Between capital spending, the schools, and the police, a substantial portion of the overall budget, then about $32 billion, was already committed. So I had to be relentless in cutting expenditures everywhere else. Each agency described the horrors that would occur if their budget forfeited a single penny, but the law stated that the budget had to be balanced, at the risk of the city's finances being taken over by the state.

On our first pass, we cut significantly from almost every one, including the Division of AIDS Services. Frankly, I didn't understand exactly what that agency did, and DAS was on the list that had been prepared by the Office of Management and Budget detailing exactly what it would take to balance the budget. The cuts would first be exposed in February's proposed budget, then I would invite the commissioners and deputy mayors in to argue their case. I'd make the final decision by the time we published the executive budget in May.

In fighting the recommendation to cut the AIDS funding, Deputy Mayor Fran Reiter, who had responsibility for that agency, made a passionate appeal, and constructed her argument with a three-pronged approach. First, she explained exactly what DAS did-how the department assisted people in finding aid from other sources, such as private charities. Second, DAS had the ability to reduce the amount and degree of incapacitation of New Yorkers suffering from HIV and AIDS, so that some people would be able to become self-sufficient, which would also relieve the cost burden on the city. Finally, much of what DAS did was to find reimbursement from the federal government, and to some extent the state government, as well as private sources. If we left the DAS budget intact, it would not immediately help the budget, but the long-term impact would be substantial, from both a humanitarian and fiscal point of view.

Fran made an effective, logical argument, exactly as a good lawyer makes when presenting the reasons a judge should decide her way. By exercising the principle to Hear People Out, I'd won a new perspective on why DAS should have retained its funding. But this was also going to be a case of Decide through Argument. A difference in philosophy had emerged regarding the appropriate role of government employees. Abe Lackman (the Budget Director) did not believe we should have people on the payroll trying to acquire private and public funds at the same time as the city was reducing its staffing levels. He recommended major cuts to DAS, which he saw as an unnecessary expense-claiming that private advocates could more effectively pressure the same private and public sources of AIDS funding.

Fran argued that Abe's position was fine in theory, but that nobody would perform as effectively as DAS. Ultimately, that would mean people would not get the level of services they needed, and at the same time the city would have fewer dollars flowing in from the federal government and elsewhere. I agreed with her, and it worked exactly as she said it would. I restored the funding, and the city ended up getting about $100 million in so-called Ryan White funding every year.

This decision also demonstrates why it's important to surround yourself with strong, independent people. If Fran hadn't been willing to take on the rest of the administration, the funding would not have been restored. She also had to confront my initial ideological response, which was closer to Abe's opinion that this was better left to private groups, at least in a city as financially strapped as New York in 1994.

I preferred our internal battles to stay that way-internal. Presenting a unified front to the public was critical. There would always be those who disagreed with a leader's decisions. Letting the public know exactly where each member of the administration stood on an issue, and who was feuding with whom, only made it easier for those who sought to exploit internal divisions for their own advantage.

Because I preferred our battles to take place behind the scenes, I would sometimes be criticized for hiring people who were reluctant to disagree with me. In addition to being a misinterpretation of my management style, that criticism was an insult to the people I hired. The fact that they didn't advertise every disagreement with me was interpreted as deferential. I call it loyalty-to me, and to the city.

There's an instructive end to the DAS budget story that provides an insight into what New York City is like. A big group came in to protest at our supposed cuts for AIDS services. By this point, Fran had won that battle-we'd reversed the cuts and actually increased DAS funding. Peter Powers saw the scheduled protest on the morning's list and told me, "I'll go out there and explain that we're actually increasing spending; maybe they'll even say something positive about you." With all the cuts, we were going through one demonstration after another-here was a chance to share some news about a program we were not cutting.

I told Peter that if he went out there he had better bring a copy of the executive budget-the protesters would never take his word for it. So he went outside and showed the leader of the protest the budget, pointing out the increase. And the guy says, "Thank you very much, but, well, we're here, we'll protest anyway." The group proceeded to protest for an hour or so, yelling, "More money! More money! Afterward, the leader sought out Peter and thanked him.

The DAS story was one of many times in which I was persuaded to change my initial position. So it's an interesting paradox. A leader has to be strong enough to make his own decisions, and stick to them even when they're unpopular; but he also must be self-confident enough to solicit opinions and change his mind without worrying that he'll appear weak.

At the beginning of my first term, I decided it was critical to the city's revival to reduce the number of sex shops. They were retarding the growth of other businesses throughout the city, particularly in Times Square. Joe Rose, my Planning Commissioner, had conducted a report that detailed how much economic activity the shops were costing the city. We made maps of where they were sited throughout the city, and started looking for ways to limit them, confident that we could use the report to justify zoning restrictions. My impulse was to use Joe's report to eliminate all or nearly all of them. Looking at the maps and seeing just how many sex stores would have to be shut, Joe Rose and Paul Crotty told me the proposal went too far. If we tried to close every shop, a judge might shoot down our entire plan, leaving us back where we started.

Joe and Paul made the case for creating a zone in Midtown in which the shops could stay open, which would not only satisfy potential concerns about oppressive restriction but would eventually give us what we wanted an yway. Since the proposed zone reduced the area available to sex shops-basically limiting them to non-residential areas-the rents in the other areas of Midtown would increase. Eventually, rents would rise even within the zone, making it too expensive for the sex shops-the free market would achieve what zoning rules couldn't. I decided that Joe and Paul were right, and we allowed the buffer zone. In the years that followed, whenever the sex shops took us to court, time after time the judges would cite this little buffer zone that we created in Midtown Manhattan as proof that the rules were not overly restrictive.

Not all decisions have the same process behind them. Some are based on objective statistics. Others are pure intuition. For example, Fran Reiter designed her DAS presentation specifically to satisfy my need for empirical evidence. She had her facts and figures at the ready. Other decisions, however, can't be supported by that sort of presentation. There might be insufficient time, or the proposal might be so innovative that data and statistics simply didn't exist. A leader shouldn't require that the value of every idea has to be proven elsewhere before embracing it-that would leave innovation out of the equation.

Important, complicated decisions require both statistical analysis and intuition. Statistics can provide the necessary data, but unless you apply your own intuition, gathered from your own experience, you are just a computer spitting out formulas. Take the decisions I made regarding prostate cancer. I based them on statistics and analysis from the best research available; but then I applied an intuitive, subjective layer about which treatment was right for me, and made the decision on my own terms, in my own time.