Hello! They don’t have to die, you can keep them alive for a very long time. If your sissy is working for you, you now have the option to prevent them from having unprotected sex, which will ensure that they won't get any stds. However, if they are about to die, you can prevent losing karma points by releasing your sissy from the dungeon. There will be a 'critically low health' warning message in the sissy's profile. If you choose to ignore it, that character will eventually die, and you will lose 1K karma points. More consumables for health increases will be added in future updates. Check out this comment for more clarity regarding karma https://itch.io/post/11529299