I'd rather have "2020 mode", let's call it.
- One save. You have to live with your choices.
- Damage increased across the board, for player and enemies, promoting less violent solutions
- Trauma Team as part of revive service, but not in all locations.
- Player can backup his personality/memories that's uploaded in a clone ( specific company), on your death: this would carry a hefty price
- Slower skill gain, higher skill tresholds, more harsh economy, prices, etc
- Survival elements? Why not...but more as stimulant than management game ( this only really works in settings where resources are scarce): you gain a slight stats/health/etc bonus for sleeping, eating regularly. If you ignore it, no penalties.
- Disable health regen from food/drinks ( etc)