Vampyr's central conflict of "uphold your oath as a doctor at the cost of being wildly underpowered, or else break your oath and betray your patients for the sake of very tempting level-ups (and, to get the best bang for your blood buck you need to learn all their deepest secrets first, thus worsening your betrayal)" is so clever, it's not immediately apparent that in a "Not Even Once" playthrough you also have to sacrifice the ability to break certain characters' storylines out of limbo.
Harvey is always waiting for his surgery, Stella and Rufus continue living under threat of a serial killer with an unpredictable temper, Carol is stuck in the house of her abusive mother, etc. There are no pacifist options here: to meaningfully change their circumstances for better or worse, you have to kill someone in their circle. The stakes are low (you can always just do another playthrough, after all), but there's almost a secondary conflict to it--do you sacrifice the best ending for Jonathan for the chance to get Carol and Rufus out of harm's way? If you do, are you just playing god the way Ackroyd accuses your experimental medical interventions of doing, cutting one life short for the Greater Good?
Anecdotally it seems many people want to take a "spare the patients who are innocent, embrace the Bad Guys like Seymour or Carolyn or Cadogan" approach, in which case the two sides of the dilemma are more completely described as:
Uphold your oath, protecting all of your patients' lives--no matter how objectively awful or dangerous they are. Lock yourself into an incredibly punishing difficulty. Earn the golden ending. Lose the ability to help certain people who need it.
Break your oath and betray your patients, taking the lives of the awful. Use their blood to fuel your own power, avoiding the worst of the difficulty the game has to offer. Lose the golden ending. Help some of the game's most vulnerable characters.
There are the bones of what could have become potential pacifist options for a few questlines, e.g. Harvey's surgery. There's already a preexisting quest where you can learn more about Strickland's dangerous experimental research and either give him the supplies he needs to perform them or inform Ackroyd of what he's been up to. The outcome of this could have been used as leverage by either party to break the deadlock. Strickland, enthused by your tacit support, pleads his case to the higher-ups and gets his way, performing the surgery and resulting in Harvey losing his arm--or Ackroyd, with the smoking gun evidence that Strickland is an active danger to his patients, performs the surgery instead, and Harvey goes home to his children, able to provide for them again with a mended arm. But as the game exists now, whether due to limited time/resources or a commitment to that secondary "you have to make sacrifices to change the world of the game, have to sacrifice not only lives but also your own happy ending" conflict, the only way to get to either outcome is to kill Strickland or Ackroyd.
Notably, however, neither Strickland or Ackroyd are pleased with the outcome when you do. If Ackroyd dies and Strickland performs the surgery, he's horrified to have cost Harvey his arm and even more resentful of Ackroyd for having been right. If Strickland dies and Ackroyd performs the surgery, he's more upset about Strickland's death than pleased about Harvey's recovery, noting that for all of the risks Strickland wanted to take he was a young, naive talent who could have become a responsible surgeon with proper oversight while he developed better insight.
There's a third option that Harvey himself proposes--why can't Jonathan do the surgery? But Jonathan turns him down, citing circumstances that mean he can't take on that responsibility right now. (Whether he means that he doesn't trust himself and his new blood thirst to perform surgery or he's simply preoccupied trying to hunt down his Maker and solve the city's myriad mysteries isn't clear, but both options are accurate. He very nearly loses control attempting to save Dorothy's patient, and his constant travels around the city will cause Ackroyd to remark that he's not present at Pembroke much.)
Jonathan will turn Harvey down regardless of whether he's refused to embrace Clay Cox/committed himself to never harming another soul or whether he's already embraced everybody in the nearby vicinity with a low enough Mesmerize level, but it hits harder in a Not Even Once run, I think. And to an extent it makes sense that he can't intervene more meaningfully anywhere else, either.
It's hard to do more than the bare minimum when you're slowly starving, after all.
yousharknotpass
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