Defining Undue Hardship: Title VII Accommodations and Mandatory COVID-19 Vaccination in Healthcare

Introduction

In Joseph Bushra v. Main Line Health, Inc., No. 24-1117 (3d Cir. Apr. 10, 2025), Dr. Joseph Bushra—a long-time emergency department attending physician and campus chief at Lankenau Medical Center—challenged Main Line Health’s mandatory COVID-19 vaccination policy under Title VII of the Civil Rights Act of 1964 (“Title VII”) and the Pennsylvania Human Relations Act (“PHRA”). After Main Line Health denied his request for a religious exemption, finding his objections insincere, it placed him on administrative suspension. Dr. Bushra sued for (1) failure to accommodate his religious beliefs and (2) retaliation. The District Court granted summary judgment to the employer, and a three-judge panel of the Third Circuit affirmed.

Key issues:

What constitutes “undue hardship” under Title VII when a healthcare employer imposes a vaccine mandate?
How strong must an employee’s evidence be to show that reasonable accommodations are possible?
What level of causal connection is required to sustain a retaliation claim arising from a denied religious exemption?

Summary of the Judgment

The Third Circuit affirmed the District Court’s grant of summary judgment in favor of Main Line Health on both the religious‐discrimination and retaliation claims. Relying principally on the “undue hardship” defense, the court held:

Main Line Health demonstrated that accommodating an unvaccinated emergency physician posed a substantial risk of COVID-19 transmission in a vulnerable patient population—an “undue hardship” under 42 U.S.C. § 2000e(j), as interpreted in Groff v. DeJoy, 600 U.S. 447 (2023).
Unrebutted expert testimony established that alternative infection‐control measures (masking, testing, cohorting) could not fully mitigate that risk.
Dr. Bushra failed to produce comparator evidence showing similarly situated employees received accommodations without posing the same hardship.
His retaliation claim faltered for lack of any non‐speculative proof that the denial of his exemption request—and not his failure to comply with the vaccination policy—caused his suspension.

Analysis

1. Precedents Cited

42 U.S.C. § 2000e(j) – Defines the religious‐accommodation obligation and “undue hardship” defense.
Groff v. DeJoy, 600 U.S. 447 (2023) – Holds that “undue hardship” means a substantial burden on an employer’s operation, considering nature, cost, size, and mission.
Atkinson v. Lafayette College, 460 F.3d 447, 454 n.6 (3d Cir. 2006) – Confirms that PHRA claims are coextensive with Title VII claims.
Kelly v. Borough of Carlisle, 622 F.3d 248, 253 (3d Cir. 2010) – Standard for de novo review of summary judgment.

2. Legal Reasoning

The court applied the familiar framework for religious‐accommodation claims:

Plaintiff’s Prima Facie Case. Plaintiff must show (a) a sincere religious belief that conflicts with an employment requirement, (b) he informed the employer of that belief, and (c) he was disciplined for failing to comply. The court assumed, arguendo, Dr. Bushra satisfied these elements.
Employer’s Undue Hardship Defense. Once a prima facie case is established, the burden shifts to the employer to demonstrate that accommodating the religious practice would impose an undue hardship “substantial in the context of [its] business.” The Third Circuit, citing Groff, stressed that in a hospital setting—where staff treat high‐risk and immunocompromised patients—even a small increased risk of COVID-19 transmission can disrupt core operations, threaten patient safety, and degrade workforce health and availability.
Evidence. Main Line Health produced expert declarations establishing that (a) unvaccinated healthcare workers have a higher probability of contracting and transmitting SARS-CoV-2, (b) frequent testing and strict masking alone do not eliminate that risk, and (c) outbreaks at similarly sized facilities led to staff shortages and patient harm. Dr. Bushra offered no contradictory expert evidence or credible comparator data.
Retaliation. To prevail, a plaintiff must show (1) protected activity (opposition to an unlawful practice), (2) adverse action, and (3) causation. Even if Dr. Bushra’s exemption request qualified as protected activity and suspension as adverse action, he failed to supply non‐speculative proof linking the two. The uncontroverted record showed that any employee who did not meet the vaccination requirement—regardless of motive—faced suspension.

3. Impact

For Healthcare Employers: This decision underscores the strength of the undue‐hardship defense in high‐stakes clinical environments. Organizations can rely on credible expert testimony and documented infection‐control data to justify categorical vaccination requirements when patient and staff safety are implicated.

For Employees: Individuals seeking religious exemptions from health‐and‐safety protocols must be prepared to counter robust employer evidence on risk. They should develop specific comparator data and, where possible, expert opinions demonstrating that proposed accommodations would be both sincere and effective.

For Courts: Bushra affirms that courts will closely scrutinize accommodation requests in contexts where public or patient health is at risk and that summary‐judgment relief remains appropriate when one side fails to introduce any genuine factual dispute.

Complex Concepts Simplified

“Reasonable Accommodation” – A modification or adjustment enabling an employee to practice their religion without undue hardship on the employer.
“Undue Hardship” – Under Title VII, an accommodation that imposes more than a minimal cost or burden. In healthcare, even slight increases in infection risk can qualify as undue hardship.
“Summary Judgment” – A court decision without trial, granted when no material factual disputes exist and the moving party is entitled to judgment as a matter of law (Fed. R. Civ. P. 56).
“Comparator Evidence” – Evidence showing how an employer treated similarly situated employees to prove discriminatory or inconsistent application of policies.
“Protected Activity” – Actions like requesting a religious exemption that oppose practices made unlawful by Title VII.

Conclusion

Joseph Bushra v. Main Line Health crystallizes the legal principle that, in healthcare contexts, mandatory vaccination policies may survive Title VII challenges when employers present undisputed evidence of substantial risk to patients and staff. It signals to courts and litigants alike that the undue‐hardship defense is particularly robust where public health considerations outweigh individual exemption requests. Employees must marshal concrete empirical or expert proof to overcome such defenses, and healthcare institutions must document their risk assessments diligently.

As vaccine mandates evolve with emerging variants and changing public‐health guidance, Bushra will remain a touchstone for balancing religious liberty against the imperative to safeguard vulnerable populations in clinical settings.