By the midpoint of the story, the number of people that have died for the Courier is staggering. Named characters are upwards of 10, with a number of generic soldiers that can only be guessed at (my estimate is in the vicinity of 100). There's even a moment in the surgery cutscene where a blood bag is taken from an injured trooper to keep the Courier alive, and all of this amounts to... nothing. There is no capacity for the courier to be damaged by this, no option to tell Blackthorne "no, you made the wrong call, you should have left me on that fucking cross". They make a big deal out of the funeral, but when they offer the courier the option to speak, the only options are one line of Fallout 3-tier "compassionate", "focused" and "sociopathic dickrag", no option to say "I know what you've been saying behind my back, and you're right. This was too much" and wrap it up with either a promise to earn back the blood spent on him or to delve into utter nihilism. Even Mass Effect did a better job of writing speeches using only two options, because they broke it up over the course of multiple inputs, allowing the player to adjust the tone of the speech over its course.
Then, just when it looked like they were going to utterly ignore all of this, we get Reign of Terror and The Shadow, an hour-long drug-induced foray into the depths of the Courier's nightmares that drags all of this back up. And how is it resolved? One line. One FUCKING line. You've seen it in the cringe compilation, the one with the "I saw myself killing you, sir" option, and then it just drops right out of the story as they move onto the next thing. If they want to imitate Kojima so hard, then where's the tearful confession? Where's the option for the courier to admit that he's just a walking avatar of death, marching from bloodbath to bloodbath, deluding himself with the belief that the rare occasions he gets to talk someone down make him a good person? Even Lonesome Road did a better job than this.
And you want the real kicker? They come back to this a THIRD time, with a sequence of the courier seeing the ghosts of fallen characters as he stumbles through the woods at night, slowly dying of blood loss and broken limbs, before moving right the fuck along to the climax and never touching it again. There could have been something fucking excellent here, but they couldn't manage their fucking ambition and actually focus on something enough to make sure they did it right.