Introduction

In this published decision, the United States Court of Appeals for the Fourth Circuit affirmed summary judgment for a hospital that denied a religious exemption to its COVID-19 vaccine mandate. The court applied the Supreme Court’s recent clarification of Title VII’s “undue hardship” standard in Groff v. DeJoy, 600 U.S. 447 (2023), and held that both health and safety risks to vulnerable patients and staff, as well as the aggregate operational disruption and costs associated with outbreaks, can constitute undue hardship. The opinion also confirms that employers may legitimately treat religious and medical accommodation requests differently because Title VII and the ADA employ distinct undue hardship standards.

Case: Carolyn Hall v. Sheppard Pratt Health System, Inc., No. 24-2048 (4th Cir. Oct. 21, 2025), opinion by Judge Wynn, joined by Chief Judge Diaz and Judge Harris, affirming the District of Maryland (Judge Adam B. Abelson).

Background and Key Facts

• Parties and Workplace: Carolyn Hall was an Admissions Coordinator at Sheppard Pratt Health System’s Center for Eating Disorders in Maryland. Her duties required in-person, close interaction with patients and families, including initial intake, paperwork, answering questions, and sometimes lengthy conversations. She shared a small office and frequently interacted with other employees.
• Patient Population and Setting: The Center’s patients were medically vulnerable, often with comorbidities including malnourishment and cardiac issues. Treatment relied on close contact and group programming—clinicians monitored meals and bathroom use to prevent purging, and human interaction was central to care.
• Pandemic Protocols and Outbreak History: Sheppard Pratt followed CDC and Maryland Department of Health guidance. Despite masking and other protocols, the facility experienced 22 COVID-19 outbreaks between September 30, 2020 and November 12, 2021, each lasting 10–38 days. Outbreak protocols included isolating patients, suspending group activities, using additional PPE, and hiring more expensive temporary staff. Admissions were curtailed during outbreaks.
• Vaccine Mandate and Exemptions: Following an August 2021 directive by the Maryland Secretary of Health requiring healthcare personnel vaccination, the hospital required first vaccine doses by September 1, 2021. It accepted medical and religious exemption requests.
  • Religious exemptions were evaluated case-by-case based on sincerely held beliefs and whether risks could be mitigated without undue hardship.
  • Medical exemptions were physician-reviewed; if approved, non-remote employees masking and weekly testing were required.
  • Over 200 religious exemption requests were submitted, with roughly two dozen granted. About 100 medical requests were submitted, over half granted.
• Hall’s Request and Termination: Hall requested a religious exemption supported by a pastor’s letter. HR assessed whether her duties could be performed remotely (they could not, a point she acknowledged). She was invited to apply for remote roles but did not. Her employment ended November 12, 2021.
• Procedural History: Hall sued under Title VII alleging failure to accommodate religious beliefs. The district court granted summary judgment for the employer. Hall appealed solely on the failure-to-accommodate theory.

Summary of the Opinion

The Fourth Circuit affirmed, holding that Sheppard Pratt met its burden to show undue hardship under Title VII as clarified in Groff. The court determined:

• Allowing Hall to remain unvaccinated posed substantial health and safety risks to medically vulnerable patients and coworkers and heightened the likelihood of disruptive outbreaks—non-economic and economic harms that qualify as undue hardship.
• Masking and weekly testing—accommodations offered to some medical-exemption holders—were less effective than vaccination at preventing transmission and were not required for religious exemptions given the different statutory standards (Title VII vs. ADA).
• The hospital reasonably considered alternatives, including remote work (which was not feasible for Hall’s role) and transfers to remote positions (which Hall declined to pursue).
• It was appropriate to consider the aggregate impact of granting similar religious exemptions to a large cohort, not merely Hall’s individual request.

Applying Groff’s “substantial increased costs in relation to the conduct of the employer’s particular business” standard, and taking account of all relevant factors, the court concluded that the hospital easily established undue hardship and therefore lawfully denied Hall’s religious accommodation request.

Analysis

1. Precedents and Authorities Driving the Decision

• Groff v. DeJoy, 600 U.S. 447 (2023): The Supreme Court rejected the “more than de minimis” gloss derived from Hardison and clarified that an employer must show that granting the accommodation would cause “substantial increased costs in relation to the conduct of its particular business.” Courts must evaluate “all relevant factors,” including the nature, size, and operating costs of the employer and the practical impact of the accommodation. Groff did not import the ADA’s more stringent “significant difficulty or expense” standard into Title VII.
• Trans World Airlines, Inc. v. Hardison, 432 U.S. 63 (1977): Although misread for decades, Hardison remains valid as clarified by Groff. Notably, Hardison recognized that courts may assess undue hardship by considering the aggregate implications of granting similar accommodations to multiple employees (see Hardison’s footnote 15), an approach the Fourth Circuit endorsed here.
• Jordan v. N.C. Nat’l Bank, 565 F.2d 72 (4th Cir. 1977): Consistent with Hardison, Jordan recognized that granting an accommodation may commit the employer to provide it broadly, entailing extra expense. Although overruled on other grounds, it supports the aggregate-impact analysis employed by the panel.
• Webb v. City of Philadelphia, 562 F.3d 256 (3d Cir. 2009): The opinion cites Webb for the principle that both economic and non-economic costs—such as threats to health and safety—can constitute undue hardship. Post-Groff, this framing retains force.
• Petersen v. Snohomish Reg’l Fire & Rescue, 150 F.4th 1211 (9th Cir. 2025): A post-Groff case concluding that allowing unvaccinated firefighters to work—even with accommodations—imposed significant health and safety costs. The Fourth Circuit found Petersen’s reasoning persuasive, particularly in public safety contexts.
• Rodrique v. Hearst Communications, Inc., 126 F.4th 85 (1st Cir. 2025): The court approvingly referenced Rodrique’s recognition that employers may reasonably rely on objective scientific information and public health guidance in concluding that vaccination reduces transmission risk relative to masking and testing.
• Bragdon v. Abbott, 524 U.S. 624 (1998): Cited via Rodrique, Bragdon supports deference to credible public health authorities when assessing contagious disease risk in the workplace.
• Lavelle-Hayden v. Legacy Health, 744 F. Supp. 3d 1135 (D. Or. 2024), and Jean-Pierre v. Naples Cmty. Hosp., Inc., 817 F. App’x 822 (11th Cir. 2020): These cases underscore that healthcare settings, as businesses involving protection of life, present acute health and safety stakes that can weigh heavily in undue hardship analysis.
• Bordeaux v. Lions Gate Ent., Inc., 703 F. Supp. 3d 1117 (C.D. Cal. 2023), aff’d, No. 23-4340, 2025 WL 655065 (9th Cir. Feb. 28, 2025): Recognized that protecting coworkers from increased transmission risk is itself a cognizable undue hardship, even after Groff.
• Fourth Circuit Title VII framework cases: Barnett v. Inova Health Care Servs., 125 F.4th 465 (4th Cir. 2025), and E.E.O.C. v. Firestone Fibers & Textiles Co., 515 F.3d 307 (4th Cir. 2008), among others, provide the burden-shifting framework and confirm that once a prima facie case is conceded, the pivotal question is undue hardship. Brooks v. Johnson and Henry v. Purnell frame the summary judgment standard of review.

2. The Court’s Legal Reasoning

The court proceeded under the familiar burden-shifting approach for Title VII religious accommodation claims. Because Sheppard Pratt conceded Hall’s prima facie case, the case turned on whether the employer met its burden under Groff to show that accommodating Hall’s religious objection would have imposed undue hardship.

Key elements of the court’s reasoning include:

• Groff’s “substantial increased costs” standard applied holistically: The court evaluated “all relevant factors,” including the nature of the Center for Eating Disorders’ operations, the vulnerability of its patient population, the frequency and consequences of prior outbreaks, and the operational, financial, and safety ramifications of additional outbreaks.
• Health and safety risks are non-economic costs that count: The opinion expressly recognizes that undue hardship encompasses non-economic harms such as increased risks to patient and employee health and safety. Given that patients were medically fragile and treatment involved close contact and group activities, permitting unvaccinated staff increased the risk of serious harm.
• Economic and operational costs were substantial: Outbreaks forced the hospital to suspend group programming, curtail admissions, procure additional PPE, and rely on more expensive temporary staffing to maintain isolation protocols. These are direct, concrete burdens “in relation to the conduct” of the hospital’s business.
• Aggregate impact properly considered: Echoing Hardison and Jordan, the court approved considering not only Hall’s exemption but also the cumulative effect of granting similar exemptions to the more than 200 employees who requested them. The aggregate risk of transmission and outbreak-related disruptions would be unacceptably high.
• Alternatives were reasonably considered and found wanting: The hospital assessed remote work and concluded (consistent with Hall’s own admissions) her job could not be performed fully remotely. It invited her to apply for remote roles—she declined. As for masking and weekly testing, the hospital provided unrebutted evidence that these measures were less effective than vaccination at limiting transmission. The court emphasized that Groff does not require employers to adopt less effective alternatives, and Title VII does not compel parity with ADA accommodations.
• Medical vs. religious exemptions need not be treated identically: The court carefully contrasted Title VII’s undue hardship standard with the ADA’s “significant difficulty or expense” standard, reaffirming that distinct statutory regimes yield distinct accommodation obligations. The hospital’s practice of offering masking/testing to some medically exempt employees did not obligate it to extend the same to religious objectors.
• Plexiglass suggestion was unpreserved and unsupported: Hall’s late-raised argument about installing plexiglass was not considered. The court noted that, even if it were, there was no evidence it would mitigate patient exposure or address coworker risk when Hall was away from the desk, underscoring that proposed accommodations must effectively mitigate the identified risks.

3. The Decision’s Fit Within Groff’s Posture

Groff re-centered Title VII analysis on the employer’s real-world burdens “in relation to the conduct of its particular business.” This opinion is a straightforward application of that direction in a healthcare setting during an active pandemic. The hospital’s substantial non-economic costs (patient and employee health risks) and economic/operational burdens (outbreak management, staffing costs, suspended admissions, disrupted programming) satisfied Groff’s threshold.

Notably, the court emphasizes that evidence-driven, case-by-case assessments—grounded in public health guidance and the facility’s actual experience—are decisive. Far from a categorical rule, the opinion reflects a tailored determination that vaccination was the most effective risk mitigation in this context, and that less protective measures would leave substantial residual risk.

4. Potential Impact and Forward-Looking Significance

• Healthcare sector: This published Fourth Circuit decision provides a clear roadmap for healthcare employers defending denials of religious exemptions where the record shows that vaccination materially reduces transmission risk and outbreaks impose significant safety and operational costs—especially with medically vulnerable populations and close-contact care models.
• Non-healthcare public safety roles: The court’s reliance on Petersen suggests alignment among circuits that, in public-facing safety-critical roles (e.g., first responders), increased transmission risk itself can meet the undue hardship threshold post-Groff.
• Aggregate-claims management: Employers may consider the cumulative effect of granting similar religious exemptions across the workforce. Policies should anticipate how large-scale exemptions affect safety, staffing, scheduling, and operations.
• ADA vs. Title VII parity: The opinion clarifies that different statutory standards justify different accommodations. Employers can, and sometimes should, offer distinct accommodations for medical disabilities without being compelled to mirror those for religious objections under Title VII.
• Evidence requirements: The decision underscores the importance of contemporaneous, objective evidence—public health guidance, internal outbreak data, operational disruption, and cost documentation—to substantiate undue hardship at summary judgment.
• Procedural discipline: Unpreserved accommodation theories (e.g., late-raised plexiglass) may be rejected; employers should document the alternatives considered, and employees should timely propose feasible measures with evidence of effectiveness.
• Post-pandemic and future public health contingencies: The reasoning is not limited to COVID-19. In future communicable disease contexts, the same framework will likely govern: where credible evidence shows substantial health/safety risks and operational burdens, denial of religious exemptions may be sustained.

Complex Concepts Simplified

• Title VII Religious Accommodation: Federal law requiring employers to reasonably accommodate employees’ sincerely held religious beliefs unless doing so would cause undue hardship to the business.
• Undue Hardship (Title VII): After Groff, the employer must show that the accommodation would result in substantial increased costs in relation to running its business. Courts consider all relevant factors, including size, nature of operations, and the accommodation’s practical impact. Both economic and non-economic costs (like health and safety) count.
• ADA vs. Title VII: The ADA’s undue hardship standard is tougher on employers—“significant difficulty or expense.” Title VII does not require that level of burden for religious accommodations. Therefore, employers may grant certain accommodations for medical disabilities without having to offer the same for religious reasons.
• Aggregate Impact: When deciding undue hardship, courts can consider what happens if many employees receive the same accommodation, not just the effect of one person’s request.
• Summary Judgment: A procedural posture where the court decides the case as a matter of law because, even viewing the evidence in the nonmoving party’s favor, there are no genuine disputes of material fact.
• Relying on Scientific Guidance: Employers may reasonably rely on objective, contemporaneous public health information (e.g., CDC/health authorities) to judge risk and the relative effectiveness of protections (e.g., vaccination vs. masking/testing).

Practical Takeaways

• For employers:
  • Document the concrete health/safety risks, outbreak history, operational impacts, and costs specific to your business.
  • Evaluate and record the feasibility and effectiveness of proposed alternatives (remote work, transfers, masking/testing, physical barriers), and explain why less protective measures would leave substantial residual risk.
  • Assess accommodation requests individually, but consider cumulative effects across similarly situated employees.
  • Be clear that ADA and Title VII have different standards and may yield different accommodations.
• For employees:
  • Offer timely, specific accommodation proposals with evidence of effectiveness in your particular workplace.
  • Be prepared to consider transfers or role modifications if core job duties require in-person contact.
  • Understand that in safety-critical environments, non-economic costs like health risks can defeat a requested accommodation under Title VII.

Conclusion

Carolyn Hall v. Sheppard Pratt Health System cements, within the Fourth Circuit, a post-Groff framework for Title VII religious accommodation disputes in healthcare. The court confirms that non-economic harms (health and safety risks to patients and coworkers) and economic/operational burdens (outbreak management, staffing, program disruption) are legitimate components of “undue hardship.” It also approves consideration of aggregate impact and rejects the notion that medical and religious accommodations must be treated identically across ADA and Title VII.

With a careful, evidence-based application of Groff, the decision provides a clear, practical template: where vaccination materially reduces transmission in a sensitive, high-contact healthcare environment, and where outbreaks entail substantial safety and operational costs, denying a religious exemption can be lawful under Title VII. As a published opinion, it will guide future cases involving communicable diseases and other safety-critical accommodations, reinforcing that the undue hardship analysis is contextual, evidence-driven, and attentive to the real-world conduct of the employer’s business.