In 1993 David Bingham is a 25-year-old paralegal descended from Hawaiian royalty who has chosen to turn his back on his heritage and lives in New York City with Charles Griffiths, a wealthy older lawyer.

In an extended flashback David's father, also named David and now in confinement at a care home, reflects on his lonely childhood as the heir to a broken dynasty and how his friend Edward encouraged him to join the Hawaiian independence movement believing that they could one day restore the monarchy, to the detriment of his relationship with his son and his own mother.

Charlie Griffiths, a childhood survivor of one pandemic, has been left physically scarred from the disease and suffers from an emotional impairment from the medicine taken to survive it.

Yanagihara began writing the book in 2016, after a conversation with her friend Jared Hohlt about the Henry James novel Washington Square.

[4] After the conversation with Hohlt, Yanagihara began writing a work set in an alternate reality in which same-sex marriage was made legal in New York in the eighteenth century.

[6] To guarantee the pandemic in the portion of To Paradise set in the future was accurate, she spoke with virologists at Rockefeller University, and the book was read by David Morens of the National Institutes of Health.

[5][6] Yanagihara wrote the novel intending to challenge the reader's conceptions of the United States, and to leave citizens of the country with "more questions than they had going in".

[10] The cover incorporates the 1898 painting I'okepa, Hawaiian Fisher Boy by Dutch painter Hubert Vos, and was created by designer Na Kim.

[14] He also questioned the role of including an alternative history of same-sex marriage in the United States, referring to it as "just randomly switching stuff around".

[14] Sacks compared the presence and purpose of the speculative history unfavorably to explorations of gender, sexuality, and related themes in other works – including The Left Hand of Darkness and The Sparsholt Affair.