Title VII Undue Hardship in Healthcare: Substantial Patient-Safety Risk from an Unvaccinated Respiratory Therapist (and a Narrow “Futility” Principle for Alternative Accommodations)

Introduction

In Charles Miller v. Charleston Area Medical Center, Inc. (4th Cir. Jan. 6, 2026) (unpublished), the Fourth Circuit affirmed summary judgment for a hospital that terminated a long-tenured respiratory therapist after he refused COVID-19 vaccination and his religious exemption request was denied. The central issue on appeal was narrow: whether accommodating Miller—by allowing him to remain unvaccinated while continuing in an in-person, patient-facing respiratory-therapy role—would impose an “undue hardship” under Title VII.

The decision arises in the wake of the Supreme Court’s recalibration of Title VII’s undue-hardship standard in Groff v. DeJoy and the Fourth Circuit’s application of that standard to healthcare vaccination mandates in Hall v. Sheppard Pratt Health System, Inc..

Summary of the Opinion

The Fourth Circuit held that the hospital established undue hardship because allowing an unvaccinated respiratory therapist to treat patients created a substantial risk to the health and safety of patients and staff—an undue hardship even without reaching the hospital’s separate argument that accommodation would jeopardize compliance with the CMS vaccination mandate. The court also rejected Miller’s contention that the hospital was required to conduct a more extensive search for alternative accommodations, concluding that, on these facts, alternative accommodations were “painstakingly obvious[ly]” futile given the essential in-person nature of respiratory therapy and the respiratory transmission risk of COVID-19.

Analysis

Precedents Cited

  • Henry v. Purnell, 652 F.3d 524 (4th Cir. 2011): Provided the de novo standard for reviewing summary judgment and the requirement to view evidence in the nonmovant’s favor.
  • E.E.O.C. v. Firestone Fibers & Textiles Co., 515 F.3d 307 (4th Cir. 2008) and Chalmers v. Tulon Co. of Richmond, 101 F.3d 1012 (4th Cir. 1996): Supplied the Fourth Circuit’s burden-shifting framework for religious-accommodation claims—prima facie case by the employee, then employer’s undue-hardship showing.
  • Groff v. DeJoy, 600 U.S. 447 (2023): Reset the undue-hardship standard, requiring an employer to show that granting accommodation would result in “substantial increased costs in relation to the conduct of its particular business,” considering “all relevant factors,” including the accommodation’s “practical impact.”
  • Trans World Airlines, Inc. v. Hardison, 432 U.S. 63 (1977): Acknowledged as the source of the prior “de minimis” phrasing later clarified by Groff, and cited for the idea that burdens can be assessed “in the aggregate” (including similarly situated employees).
  • Hall v. Sheppard Pratt Health System, Inc., 155 F.4th 747 (2025): The Fourth Circuit’s key comparator case involving a healthcare employer’s denial of a COVID-19 vaccine religious exemption. Hall emphasized that undue hardship includes both economic and non-economic costs, including “threats to the health and safety of employees and the people they serve,” and that burden may be evaluated in the aggregate.
  • Hanlon v. Chambers, 464 S.E.2d 741 (W. Va. 1995): Used to align WVHRA analysis with prevailing Title VII doctrine absent meaningful statutory differences—supporting the Fourth Circuit’s decision to apply the same undue-hardship reasoning to both Title VII and WVHRA claims.
  • Smith v. City of Atl. City, 138 F.4th 759 (3d Cir. 2025) and Bordeaux v. Lions Gate Ent., Inc., No. 23-4340, 2025 WL 655065 (9th Cir. Feb. 28, 2025): Cited as persuasive authority recognizing that, even post-Groff, an employer may treat further accommodation exploration as futile where undue hardship is evident.
  • Miller v. Charleston Area Med. Ctr., No. 2:23-cv-340, 2024 WL 4518293 (S.D.W. Va. Oct. 17, 2024): The district court decision affirmed, notable for its characterization that alternative arrangements were “painstakingly obvious[ly]” unavailable for an unvaccinated respiratory therapist treating respiratory patients.

Legal Reasoning

  1. Issue narrowing and posture. The district court assumed (without deciding) that Miller could make out a prima facie case, and the Fourth Circuit likewise addressed only undue hardship. This is significant: the court did not decide whether Miller’s objections were “religious” or “sincere,” because the employer prevails if it independently proves undue hardship.
  2. Application of Groff through Hall. The panel treated Hall as nearly dispositive because both cases involved healthcare workers with direct patient and staff contact, where vaccine refusal increased transmission risk in a medical setting. The court highlighted Hall’s recognition that “non-economic costs” (especially health-and-safety threats) can satisfy the “substantial increased costs” concept after Groff, when evaluated in light of the employer’s particular business.
  3. Undue hardship based on health-and-safety risk alone. Although the hospital also raised potential CMS compliance and funding risks, the Fourth Circuit affirmed without reaching those arguments, holding that the “increased risk of transmission alone” was enough. For a respiratory therapist—whose duties include ventilator management and close contact with respiratory patients—the court accepted the hospital’s conclusion that an unvaccinated clinician created an unacceptable risk to “patients, families, staff, volunteers, visitors, and health care providers.”
  4. Alternative accommodations and a narrow “futility” concept. Miller argued the hospital failed to provide an individualized assessment or consider alternatives. The court acknowledged the record showed less “brainstorming” than in Hall, but rejected any notion that Hall created a mandatory checklist. Critically, the court distinguished roles: unlike an admissions coordinator (who plausibly could perform some work remotely), a respiratory therapist’s “core job duties” require in-person treatment of particularly vulnerable patients. On these facts, searching for alternatives was treated as futile—while the court cautioned that such futility circumstances are “rarely presented.”
  5. WVHRA alignment. Using Hanlon v. Chambers, the court treated West Virginia law as tracking Title VII’s approach here, extending the same undue-hardship analysis to both claims.

Impact

  • Healthcare employers gain a clearer pathway under Groff for patient-safety-based undue hardship. This opinion reinforces that “substantial increased costs” are not limited to dollars; they include substantial operational and safety burdens where the employer’s business is clinical care and infection prevention.
  • Role-specific analysis becomes central. The court’s reasoning turns on job functions: in-person, close-contact clinical roles (especially respiratory-focused roles) may present a stronger undue-hardship case than administrative roles where remote or segregated work is plausible.
  • Limits (and risks) of the “futility” rationale. While the panel accepted futility here, it warned that true futility is rare. Future employers may cite this decision to justify declining to explore alternatives, but the opinion suggests courts should confine that approach to situations where the mismatch between job duties and requested accommodation is obvious (e.g., essential in-person care for vulnerable patients during a contagious respiratory pandemic).
  • Unpublished status. The court noted the opinion is unpublished and “not binding precedent,” but it still signals how the Fourth Circuit is likely to analyze similar facts, especially given its heavy reliance on Hall.

Complex Concepts Simplified

Religious accommodation (Title VII)
If an employee has a bona fide religious belief that conflicts with a workplace rule, the employer must provide a reasonable accommodation unless doing so would create an “undue hardship.”
Undue hardship after Groff
Not “any” burden suffices. The employer must show the accommodation would impose “substantial increased costs” in light of its business. In healthcare, the “cost” can be substantial safety and operational risk, not just money.
Non-economic costs
Burdens that are not direct financial expenses—such as heightened risk of infection, disruption to patient care, and threats to employee and patient safety—can still qualify as “costs” relevant to undue hardship.
Considering burdens “in the aggregate”
Courts may consider what happens if multiple similarly situated employees seek the same accommodation, not just the impact of accommodating a single employee.
“Futility” in searching for alternative accommodations
In rare cases, where it is obvious that no alternative arrangement can avoid undue hardship given the job’s essential functions, the employer may not need an extensive exploration of alternatives. The Fourth Circuit treated this case as one of those rare instances.

Conclusion

The Fourth Circuit affirmed that, under Groff as applied in Hall, a healthcare employer may deny a COVID-19 vaccine religious exemption when accommodating an unvaccinated, patient-facing clinician would create a substantial health-and-safety risk—an undue hardship in relation to the employer’s business of providing safe medical care. The opinion also recognizes a narrow, fact-driven “futility” principle: where the job’s essential functions (here, in-person respiratory therapy) make alternative accommodations plainly unworkable, an employer’s failure to propose or test alternatives will not necessarily defeat an undue-hardship defense.