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Remember that Ethan isnt an average human, hence why he has those visions and pukes so many times, it also has to do with Hate and some kind of sonic transmitting driving everyone nuts in the city.
Leland was basically a muppet under the influence of Hate, killing him or leaving him alive wouldnt have saved the day for anyone when you think about it, especially when Malcolm finally managed to neutralise his nephew
There is a sonic field emanating from within the city. The game has us suppose that the source is the creature Thomas fights at the end, but then in the ending cutscene, Thomas' psychosis continues as he hallucinates the oral Oro device while in the bathroom. Thomas' psychosis and the psychosis of the troubled citizenry all still emanate from this one source, which remains a mystery for the 2nd game.
Edit: I've watched the ending some more, and I'm ready to suggest that the device on Thomas' face is a vocal amplifier that somehow uses hydraulics or something to alter the vibrations of the air as attuned to the user's vocally selected frequencies. This allows the user to control people through psychosis -- hallucinations and paranoia. The player has essentially appropriated the power which VanHorn sought to control through his manipulation of both Leland and Thomas.
EDIT EDIT: ♥♥♥♥ me sideways its a facehugger
There's a Thread in here with detailed instructions on how to get it running on a pc.
It's pretty easy.
Edit:
There you go:
https://steamcommunity.com/app/4720/discussions/0/864949719261360206/?ctp=76
Read pages 76 to 77 and you're good to go. Hope this helps