A LOT OF US READING THE PAPER TODAY have an excellent chance of being around 30, 40 and maybe even 50 years from now. While generally that is good news, it could create some serious ethical problems with health insurance in our lifetimes.

There is no question but that we are on the frontier of major medical advances. Only recently new forms of vaccines were invented that use genetic engineering techniques. There were major advances in heart, liver and kidney transplants with the advent and improvement in the use of immunity-suppressing drugs.But it is unlikely, in this age of Gramm-Rudman and burgeoning budget deficits, that Congress will make heart or liver transplants an automatic, free public program.

The question is: Who will pay?

If private insurers follow their current direction, they will offer coverage of such high-cost medical procedures as part of major medical expenses. That's fine for those who are employed or are the dependents of those with good jobs.

But where does that leave the unemployed, those with less generous benefits or those with individual policies that are far less likely to offer such benefits without exorbitant premiums?

Where does it leave health maintenance organizations and other new health- care delivery systems? And where, indeed, would this leave Medicare patients in need of transplants not covered by that program?

Among those in need, will society pay for a replacement liver for an alcoholic or a lung transplant for a heavy smoker?

This country has never been good at discussing ethical questions in economic terms, even when the costs to society could be substantial. Can we reach a national consensus on who should be a prospect for an organ transplant? Would a country delighting in the physical ability of its 75-year- old president determine that those eligible for Medicare are too old for organ transplants?

The prospect of heart transplants for every older person whose heart is wearing out is mind-boggling. But if the power to extend life is in the hands of our physicians, who will have the responsibility of saying no?

We have no answers. But we think these questions need to be considered.

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