Community Building&Planetary Boundaries in Min-i-ren

Summary

The text analyzes the evolution of the ideals of Min-i-ren (a Japanese medical and welfare association, short for Federation of Japanese Democratic Medical Institutions), rooted in the strong foundation of "egalitarianism in Japanese popular society." This core has dynamically incorporated major ideological trends over time.

Key Evolutions of Min-i-ren Ideals:

1. Response to Global Shifts (2010 Charter): Following the collapse of the Soviet Union, China's authoritarianism, and the rise of neoliberalism, Min-i-ren shifted its grounding from Marxism to the Japanese Constitution and the UN Charter.

2. Incorporation of the "Ethics of Justice": Deepening its alignment with liberal egalitarianism (e.g., International Covenants on Human Rights), the organization embraced the knowledge of Social Determinants of Health (SDH), viewing health-damaging disparities as "injustice" and incorporating principles like "Justice as Fairness" and "Capability Equality."

3. Integration with the "Ethics of Care" (2020s): Beyond the "Ethics of Justice," the organization integrated the feminist-derived "Ethics of Care," which emphasizes equality between care recipients and providers, the equality of taking on care responsibilities, and the intrinsic significance of care for humanity.

Min-i-ren's Response to Three Criticisms of Modern Medicine:

The changes in Min-i-ren's ideals are seen as responses to three major criticisms of late 20th-century modern medicine:

1. Harmfulness: Min-i-ren responded by prioritizing "Clinical Ethics," "Quality of Care," and "Medical Safety."

2. Narrow Scope: They pioneered the adoption of socio-epidemiology (Michael Marmot, et al.), leading the effort on Social Determinants of Health (SDH), which addresses the 60-80\% of health impediments attributed to social and natural environment factors.

3. Excessive Division of Labor: They promoted General and Family Medicine, emphasizing the patient's whole person, emotional life, and the healthcare provider-patient relationship, with the "Ethics of Care" as its backbone.

Future Challenge: "Planetary Boundaries" and Min-i-ren

The core of the presentation concludes with a prediction: Min-i-ren's next groundbreaking ideal will emerge as a response to the "Planetary Boundaries," the ecological crises caused by the expansion of capitalist productivity.

The author predicts that Min-i-ren's long-standing goal of "Community Building (Machizukuri) where people can live with peace of mind" will merge with "Degrowth" theory, creating a new, epoch-making ideal. This will involve abandoning production-first thinking and prioritizing residents' and local autonomy (Municipalism), specifically aiming for "Care Self-Sufficiency" in essential services like healthcare, long-term care, childcare, and education within each living area. The author asserts that Min-i-ren's "Machizukuri" framework will play a historically decisive role in achieving this "Care Self-Sufficiency."

English Translation

"Community Building" (Machizukuri) and "Planetary Boundaries" in Min-i-ren

Introduction: The Evolution of Min-i-ren's Ideals

Since its founding in 1953, Min-i-ren has revised its platform three times and currently operates under its fourth platform. I particularly wanted to deeply examine the background of the 2010 platform revision based on the situations in Japan and the world.

In my previous presentation in Kanazawa, I analyzed the changes in Min-i-ren's ideals since 1990. My conclusion was that Min-i-ren's ideals have been formed by the constant combination (vector synthesis) of major ideological trends of each era with the strong foundation of "egalitarianism in Japanese popular society" that has existed consistently since before the platform's establishment. I believe I have captured this dynamic process of ideal formation to some extent.

Concrete Changes in Ideals

• Background of the 2010 Platform Revision: Amidst major upheavals, symbolized by the 1990 Soviet collapse, the rise of Chinese authoritarianism (Tiananmen Square Incident), and the global sweep of neoliberalism, Min-i-ren sought the basis for its activities not only in Marxism (the most influential ideology at the time) but also, once again, in the Japanese Constitution and the UN Charter.

• Incorporation of the "Ethics of Justice":

Following this, it deepened its alignment with liberal egalitarianism, such as the International Covenants on Human Rights.

In particular, the findings on the "Social Determinants of Health (SDH)" advocated by Michael Marmot and others became a major turning point. This led to viewing disparities harmful to health as "injustice" and incorporating the "Ethics of Justice" into its ideals, such as "Justice as Fairness" and "Capability Equality."

• Integration with the "Ethics of Care":

In the 2020s, in addition to the "Ethics of Justice" aimed at correcting socio-economic disparities, integration with the "Ethics of Care," which originated from feminism, became prominent.

This means incorporating into the ideals not only equality between care recipients and providers but also the equality of taking on care responsibilities and the essential significance of care for human beings.

Current Attempt: Min-i-ren's Ideals and Critique of Modern Medicine

In this current consideration, while building upon previous studies, I have re-examined the perspectives by drawing closer to medical activities. The changes in Min-i-ren's ideals can be understood as a response to the following three major criticisms leveled against modern medicine in the late 20th century:

1. Harmfulness of Modern Medicine: The visibility of harms such as drug-induced diseases and medical accidents that claimed many lives, and the excessive growth of "power" held by doctors and hospitals.

2. Narrow Scope of Modern Medicine: Criticism of the bias in research toward biological subjects like microbes and genes, neglecting society and the natural environment. (Biological factors are estimated to account for only 20-40\% of all health impediments, with the remaining 60-80\% attributed to social and natural environment factors.)

3. Excessive Division of Labor in Modern Medicine: Criticism that the human being has been reduced to a collection of organs, losing sight of the goal of holistic well-being and dignity.

Min-i-ren responded to these criticisms as follows:

1. Response to the 1st Criticism (Harmfulness): Emphasis on "Clinical Ethics," "Quality of Care," and "Medical Safety." This corresponds to Min-i-ren's policy of "improving overall quality of medical and nursing care centered on safety, ethics, and collaborative activity." (Clinical Ethics is equivalent to corporate ethics in other industries.)

2. Response to the 2nd Criticism (Narrow Scope): Advanced adoption of social epidemiology (Michael Marmot, et al.), pioneering work on the Social Determinants of Health (SDH). It can be said that it would have been difficult for SDH to become a required subject in medical school curricula without Min-i-ren's dissemination activities, highlighting its pioneering role.

3. Response to the 3rd Criticism (Excessive Division of Labor): Promotion of General and Family Medicine. This discipline, which emphasizes the patient's emotions, life process, and emotional exchange with healthcare providers, has become the mainstream of Min-i-ren's physician training and influences all its medical activities. The "Ethics of Care" forms the backbone of this discipline.

When summarizing these responses in a diagram (implied), it shows a cross-section of Min-i-ren's current medical philosophy structure. It is important to note several keywords here. It also shows that the character of an organization or society can be expressed by which of the "Three Ethics" (constantly present in medical and nursing care) is emphasized. Furthermore, translating this into practice leads to an integrated clinical model that unifies the three domains of "disease," "person," and "society."

Future Challenge: Planetary Boundaries and Min-i-ren

Building on the above, I now finally state the core of this presentation: what new ideals Min-i-ren, with its foundation in Japanese popular egalitarianism, will create next.

This will appear as a response to the fracture that the expansion of capitalist productivity brings to the natural environment, namely the "Planetary Boundaries."

Current international affairs (such as the genocide in Gaza and Trump's politics) must also be related to the strategy of the ruling and wealthy classes trying to secure their own survival environment.

My prediction is that "Community Building (Machizukuri) where people can live with peace of mind," which has been one of many goals, will merge with "Degrowth" theory to leap forward into Min-i-ren's new, groundbreaking ideal.

While "Degrowth" theory has not yet been formally debated within Min-i-ren, it shares the common ground of abandoning production-first thinking and making resident sovereignty/local autonomy (Municipalism) the first step in practice.

Concretely, this is none other than aiming for "Care Self-Sufficiency"—in healthcare, long-term care, childcare, and education—within each living area. I am confident that Min-i-ren's "Machizukuri" discourse will play a historically decisive role in achieving this "Care Self-Sufficiency." This is only my current prediction, but persistent, steady effort is the path to approach it, and I presented this idea to emphasize the future importance of "Machizukuri."

It's Okay to have only one person

The renowned Japanese critic, the lateKato Shuichi , stated, "It's okay to be alone." -?- This statement does not advocate for the stoic endurance of elderly men's solitary lives. Instead, it highlights the significant impact of having foreign friends in enhancing one's sensitivity towards peace,'' It's Okay to have only one person'',

in Japanese it means also ''being alone.''

This concept might be a tangible manifestation of the peace vision that constitutional scholar Aoi Miho  describes as "going beyond Article 9, transcending nations."

I consider myself somewhat qualified since I have invited Dr. Seoc-Kyun Woo (Co-Representative of the Korean Humanitarian Physicians Association) to give a lecture in Ube and have become acquainted with him for a long time. The interpreter, Ms.Huang, may only have a professional connection there, so it could simply be a one-way communication.

Hence, I believe that providing opportunities to individuals in my surroundings who lack such chances is a form of my servant leadership, albeit in a limited capacity.

For example, by continuing the book club of Han Kang, the preeminent female novelist in Korea, and eventually reaching a joint reading session with corresponding groups in Korea.

Listening to the Lecture by Miho Aoi

In the midst of work, I listened to a lecture by Miho Aoi、aconstitutional scholar. It had almost the same content as the May issue of the magazine "Sekai" (Iwanami Shoten).

The amendment to the security legislation, which allows for the exercise of force (collective self-defense) in situations of 'existential crisis', has deprived the nation of a clear recognition of "attacks on our country."

Since then, the government's interpretation of the constitution has lost any basis or reference point.

At the same time, it has become evident that the government considers the involvement and deaths of citizens as 'collateral damage 'in the event of a counterattack by the enemy.

Remembering and Reflecting

On a Saturday afternoon（July 1st), while diligently working on notations for stacked receipts of Health Insurance, heavy rain caused a transportation disruption. The next on-call doctor who was supposed to come from afar couldn't make it in time, so I had to fill in for a while. Today was supposed to be sunny, but the rain has intensified once again.

During that time, I received a long-awaited call from my cousin. He said, "Today is the third anniversary of your father's passing."  The heavy rain from last night had completely slipped my mind. It was two years ago on this very day that I witnessed his last moments as his attending physician.

We held the funeral with just my son and me, but it feels like a distant memory. My father was a Shinto priest, but he liked to

be buried in the family grave of the Jodo Shinshu sect. Yet, we still haven't been able to make arrangements for the gathering of relatives for the interment.

My cousin, who grew up in the snowy mountains of western Chugoku japan, has a different passion for skiing compared to me. He even obtained a ski instructor certification, which recently led him to move to Azumino in Nagano.

As he reminisced about me, he also mentioned his older brother, who passed away at the same age as me. He added, "We probably won't see each other again, but take care." While it's true that we won't meet at each other's funerals, it was a rather premature greeting.

I naturally recalled the passing of another cousin who didn't inform us about his illness until the end.He passed in the last month.

A Call for Dissent: Asahi Shimbun, July 1st

In an article published in the Asahi Shimbun on July 1st, titled "A Call for Dissent," Keishi Saeki (Kyoto University), a prominent figure among Japanese communitarians, expressed his view that "Hosting the G7 in Hiroshima and inviting Zelensky to participate signifies a declaration of hostility towards Russia through nuclear means." In other words, it is an appeal to add the same destruction inflicted on Hiroshima1945 to Russian cities.

Considering that the United States, which approves of the atomic bombings as a means to end World War II, is behind this decision, it is only natural to interpret it in this way. It is likely that the same logic is believed to be effective in dealing with Russia.

According to Saeki, Hiroshima has been dragged down from being a symbol of peace and has now become a place for declaring a commitment to the use of nuclear weapons.

Saeki suggests that Japan's traditions may hold the key to breaking free from the military confrontation between American domination and the Russo-Chinese alliance. However, the desired outcome may be right, but the desired path differs.

We must not turn away from the challenging path of a peace plan based on transnational citizen solidarity, as there is no longer any reliance on nation-states alone.

the annual general meeting of the Nonprofit Cooperative Research Institute "LIFE and LIVING."

On June 17，2023、I participated remotely in the annual general meeting of the Nonprofit Cooperative Research Institute"LIFE and LIVING." The meeting lasted for three hours, and I focused on the screen with some nervousness as I wanted to speak during the discussions.

There were three presentations related to the future vision of a Physicians Union  of Japan(Min-iren), followed by a discussion. First, Chairman Nakagawa　Yuichiro addressed the issue of Okinawa. While it may not be exactly as he stated, I personally confirmed the need to always reflect on the current situation in Okinawa, which can be considered as ground zero, when considering future peace plans, namely human security and the inviolability of individuals' right to peaceful existence. (Fukushima also stands as a place with similar significance.)

Next, Vice Chairman Goto　Michio discussed the interpretation of "nonprofit" and "cooperative." It was highly stimulating and relevant to my subsequent statement, so I summarized my thoughts there.

The third presentation vividly demonstrated the evolution of Min-i-ren's vision by President of Min-i-ren Masuda Takeshi. However, I felt that the changes were not merely internal and natural phenomena within Min-iren but were deeply connected to external transformations, so I had some reservations.

Now,  I would like to briefly supplement what I said in discusson, without the constraints of time:

Even outside of Min-i-ren,many private and public hospitals inJapan are fundamentally "nonprofit." It is well known that the Japan Medical Association characterizes itself as "social common capital" using terminology borrowed from Hirofumi Uzawa. However, the possibility of nonprofit private hospitals and public institutions truly developing their nature is virtually nonexistent. They will only be tossed around by neoliberalism. This is because "cooperativeness" is essential to maintain a nonprofit status. In terms of the terminology I came up with a year ago, "cooperativeness" would be equivalent to "basic local autonomy." I believe the meaning of "basic local autonomy" can be imagined based on Min-i-ren's open operation in the community alongside cooperative organizations, ensuring transparency to residents through the General Assembly, which acts as a parliament, and the Board of Directors, which acts as the executive body.

So, how can public institutions and governmental hospitals acquire "cooperativeness" and become "basic local autonomous" entities? The need for such awareness arises because even if Min-i-ren alone boasts "cooperativeness," it will have little impact on the entire population. Many hospitals in the community must adopt strategies that lead to such an outcome.

There are several possible paths, but the most viable one is for municipalities to shift towards regional sovereignty and establish "hospital management committees with resident participation" or request hospitals to include representatives of residents and patients in their board of directors. Symbolic changes could occur, such as the hospital meals becoming locally sourced, which may seem insignificant but hold significance.

To achieve the realization of a new welfare state that liberates the people from poverty and inequality, it is essential for municipalities to develop under the principle of regional sovereignty. And it is the prefectural organizations within Min-i-ren that are closest to becoming the catalysts for such movements.

My Min-i-ren(4)

The WHO-SDH Committee, chaired by Michael Marmot, released its final report in 2008 titled "Closing the Gap in a Generation," solidifying its unwavering health strategy.

It can be said that at this time, declarations regarding the right to health finally became substantive.

Within Japan, a  Physicians Union (Min-i-ren) took the lead in earnestly studying this third health strategy, leading to the convergence of Min-i-ren's principles and a new health promotion based on the Social Determinants of Health (SDH). The phrase "Solid Facts," conveying the significance of considering SDH as undeniable facts, became the rallying cry for Min-i-ren as a whole. The attitude of perceiving illness from the perspectives of work and life, which naturally emerged as a characteristic of Min-i-ren in the late 1960s, was interpreted as being pioneering in its awareness of SDH.

It was at this time that the intention to rebrand the previously cherished term "right to life" to align with the global trend as the "right to health" became apparent.

For Min-i-ren, the right to health is nothing other than the right to life achieved through a health strategy based on SDH.

My Min-i-ren(3)

The Constitution of Japan advocates popular sovereignty and the right to peaceful existence, and establishes basic human rights as universal rights that have been acquired through the long-standing freedom of humanity and can never be violated. However, these rights are being neglected. We uphold the ideals of this constitution, further develop our progress, and strive for a society where all people are equally respected as human beings."

In this case, a problem arises as to whether the name "right to life," which can also be interpreted as guaranteeing only the minimum line of survival, is appropriate as the name for the human rights we aim for. Therefore, the term "right to health" comes to mind. However, the movement fought under the name of the right to life, especially the lawsuit brought against the state by Asahi Shigeru, a brave tuberculosis patient, based on Article 25 of the Constitution, which is known as a "human rights trial," has strongly remained in people's memories, and there is a deep attachment to the term "right to life" created through that process.

The issue of "right to exist or right to health" seems to be simply a matter of nomenclature, but accepting the name "right to health" required the discovery and convergence of another idea. This will be discussed in the next chapter.

2. Declaration of the Right to Health or Health Strategy

The right to exist mentioned in Japan's constitution is referred to as the right to health on a global scale.

The right to health was established as a wording in the WHO Constitution in 1948 and the Universal Declaration of Human Rights. Since then, similar content has been repeatedly declared in the International Covenant on Economic, Social and Cultural Rights, Article 12 (1976), and the General Comment No. 14 on the Right to Health of the International Covenant on Economic, Social and Cultural Rights (2000).

The International Covenant on Economic, Social and Cultural Rights, General Comment No. 14 on the Right to Health (2000):

Health is a fundamental human right indispensable for the exercise of other human rights. Every human being has the right to the highest attainable standard of health in order to live a dignified life.

In fact, the repetition of such declarations implies that mere declarations alone have not brought about any real change. This is similar to the criticism Amartya Sen directed at John Rawls. Sen argued that there are two approaches to justice: 1) those who try to achieve perfect justice by creating ideal systems or laws (Kant, Rawls), and 2) those who try to remove evident injustice from the world (Marx, Sen).

As this criticism suggests, in order for the right to health to be realized, repeating ideal declarations is meaningless, and some concrete practical strategies are required.

The start of the health strategy was the Alma-Ata Declaration in 1978. However, the first phase of the health strategy, Primary Health Care, was confined within a non-political framework due to the power struggle between the United States and the Soviet Union, and it remained partial and selective.

The second phase of the health strategy, Health Promotion, which started with the Ottawa Charter in 1986, also placed emphasis on "individual empowerment" based on personal responsibility, rather than social reform, amidst the onslaught of neoliberalism. In Japan, the government-led movement called "Health Japan 21" was launched by the Ministry of Health, Labour and Welfare but achieved little success.

The prospect of actually improving the health of people around the world was obtained when Michael Marmot established the Social Determinants of Health (SDH) and the third phase of the health strategy, Health Promotion based on SDH, emerged.

My Min-i-ren(2)

In such a complex situation, the left-wing in Japan had long refrained from fully affirming the constitution. They aimed to adhere to and develop only selected "democratic provisions," such as the Preamble and Article 9.

However, the push for constitutional revision by the Liberal Democratic Party (LDP) gradually gained momentum since Prime Minister Nakasone in the 1980s, which prompted the left-wing forces to reconsider the constitution.

The current Emperor fulfills the role of a symbol of national unity without holding political powers as a head of state. It is considered incorrect to classify Japan as a monarchy like the United Kingdom or the Netherlands. As a result, the entire constitution, including the Emperor's provisions, became the subject of adherence.

There has also been a change in attitude towards Article 25 of the constitution. Research since 1990 revealed that Article 25 was not originally present in the draft constitution by the Allied Occupation GHQ but was inserted based on a proposal by Suzuki Yoshio, a member of the Social Democratic Party, and named the "right to life" by Seino Kikuko and others. It is said that Suzuki Yoshio referred to Article 151, Paragraph 1 of the Weimar Constitution of Germany (1919).

Weimar Constitution, Article 151 (Order of Economic Life, Economic Liberty)

1. The order of economic life must conform to principles of justice aiming to ensure a life worthy of human beings for everyone. The economic freedom of individuals shall be secured within these limits.

However, it is correct to say that Suzuki's proposal actually inherited the concept of the right to life brought back to Japan by Fukuda Tokuzo, a pre-war welfare economist who studied in Germany in 1900. Fukuda became famous for advocating for "human recovery" based on the right to existence when he led students from Hitotsubashi University to investigate the damage caused by the Great Kanto Earthquake ,1923. Approximately 90 years later, "human recovery" became our rallying cry in the reconstruction after the Great East Japan Earthquake on March 11, 2011.

In his writings, Fukuda Tokuzo mentioned that he inherited the concept of the right to life from Anton Menger (1841-1906), a German socialist legal scholar who was heavily influenced by Fabian socialism in England.

With the revelation of this unique history related to the right to life in Japan, an even more significant development occurred. The meaning of the right to life had been changing significantly due to the progress of Japan's social security movement. It was moving beyond being the basis for the relief of people below the poverty line, as stated in Article 25, to striving for the principle of a welfare state that "ensures a healthy and culturally rich life for all individuals," including those above the poverty line.

When considering this alongside the Constitution's Article 9, which advocates for the renouncement of war, it can be seen that a fundamentally different and groundbreaking image of a welfare state emerged under the framework of Article 25. This welfare state image holds a characteristic of fundamentally confronting the neoliberal global order, which assumes incessant wars led by the United States.

In this way, the positioning of Article 25 and the right to life in Japan's left-wing movement underwent significant changes and became more relatable. The declaration made by the Japan Federation of Medical Workers' Unions (Min-iren) in their new manifesto in 2010 can be seen as an expression of the confluence of Min-iren's ideals with Article 25 of the constitution.

MY Min-i-ren(1)

The Min-i-ren movement is not just a post-World War II democratization movement in Japanese healthcare that continues to this day. It aims to inherit the entirety of the history of popular-oriented healthcare in Japan. It may possibly trace its roots to the depths of Japanese history.

Examples of this history include medical practices by Buddhist monk Ninsho in the Kamakura period (13th century), the book "Yojokun" by Kaibara Ekiken in the early Edo period (17th century), and the book "Shizensineido" by Ando Shoeki in the mid-Edo period (18th century). Among them, Ninsho conducted a wide range of medical activities for patients, including those with leprosy, based at Gokurakuji Temple in Kamakura. Ando Shoeki, on the other hand, was a staunch advocate of equality and a fierce critic of the feudalistic caste system during the Edo period. The Min-i-ren movement is not simply a post-World War II democratization movement in Japanese healthcare.

Instead, it seeks to carry forward the entirety of the history of popular-oriented healthcare in Japan, which may potentially delve deep into the roots of Japanese history. However, further elaboration on these matters is not possible.

The direct predecessor of the Min-i-ren movement is the "Musansya Sinryosho" movement, a proletarian healthcare institution movement born out of the convergence of popular-oriented healthcare and Marxism before World War II. The movement to establish healthcare institutions for workers and farmers, sparked by the funeral of assassinated Labor-Farmer Party representative Yamamoto Senji, quickly spread nationwide. However, this movement was violently crushed by pre-war militaristic Japan.

After World War II, the Min-i-ren, established in 1953, aimed to inherit the pre-war Musansya Sinryosho movement and not only merged with Marxism but also integrated with various ideologies, which has become a characteristic feature of the movement today.

Among these integrations, the confluence with Article 25 of the Japanese Constitution, "the right to a minimum standard of living," the confluence with the "right to health" represented by the Universal Declaration of Human Rights, and the convergence with the WHO's health strategies have occurred continuously in a relatively short period. As a result, the recent aspect of the Min-i-ren movement has significantly changed compared to the first half of its history.

Therefore, in this discussion, I would like to trace the changes in the ideology of the Min-i-ren movement regarding two controversial issues: (1) the right to life or the right to health, and (2) the Declaration of the Right to Health or the WHO's health strategies.

1. Rediscovery and convergence of Article 25 of the Constitution, the right to life

Article 25 of the Japanese Constitution:

"All people shall have the right to maintain the minimum standards of wholesome and cultured living."

The Japanese Constitution was established shortly after World War II under the strong guidance of the General Headquarters of the Allied Occupation (GHQ) (1947). It was a groundbreaking document that advocated peaceful survival rights, national sovereignty, and the renunciation of war potential. However, reflecting the compromise of the US-Japan ruling class, it prioritized provisions regarding the Emperor, ensuring that the Emperor would not be held accountable for the war. Moreover, shortly after the Constitution was established, under the intensifying Cold War between the US and the Soviet Union, with Japan being de facto subjugated by the US, the US began its efforts to modify Japan's renunciation of war potential (Article 9). In the end, the Constitution could not be changed, and the unconstitutional Self-Defense Forces were established as Japan's, (be continued)