Undue Hardship in Pediatric Healthcare: Sixth Circuit affirms that exempting an unvaccinated employee from COVID-19 testing constitutes an undue hardship under Groff

Introduction

In Wise v. Children’s Hospital Medical Center of Akron, the Sixth Circuit (in a nonprecedential opinion) affirmed summary judgment for a pediatric hospital that discharged a staff pharmacist who refused both COVID-19 vaccination and COVID-19 testing on religious grounds. The panel held that, even assuming the employee established a prima facie case of religious discrimination under Title VII, the hospital proved that accommodating a testing exemption would impose an undue hardship—particularly given the hospital’s mission to protect highly vulnerable pediatric patients and the operational realities of a contained pharmacy environment with overlapping shifts. The court likewise affirmed on the related retaliation claim.

The decision is an important post-Groff application of Title VII’s “undue hardship” standard to a healthcare setting during an infectious-disease crisis. It reinforces that, for hospitals caring for immunocompromised and infant patients, allowing an unvaccinated employee to forgo routine COVID-19 testing can pose a substantial risk to patient safety and staffing stability—an undue hardship that defeats the accommodation claim even without evidence of realized harm.

Summary of the Opinion

Plaintiff Tina Wise, a long-tenured staff pharmacist, declined vaccination and, invoking religious beliefs, sought exemption from both COVID-19 vaccination and COVID-19 testing. The hospital granted her vaccine exemption but denied the testing exemption, citing safety and federal mitigation obligations. After a 90-day post-infection reprieve expired, Wise refused to resume testing. Following warnings, the hospital terminated her employment.

Wise sued for failure to accommodate and retaliation under Title VII. The district court granted summary judgment to the hospital, finding undue hardship. On appeal, the Sixth Circuit affirmed de novo, concluding:

Even assuming Wise established a prima facie case, the hospital met its burden to show undue hardship under Title VII as defined in Groff v. DeJoy.
Key factors included the hospital’s pediatric mission, the extreme vulnerability of its patients (NICU, oncology, immunocompromised), the risk profile of Wise’s role (contained pharmacy, overlapping shifts, exposure to many colleagues), the necessity of testing to verify non-infectiousness, the cumulative impact of similar exemption requests (at least 35 others), and staffing risks.
The hospital need not show concrete, realized harm; foreseeable substantial risks and safety considerations suffice.
Alleged inconsistencies in evolving COVID policies did not render the hospital’s judgment unreasonable; courts should not second-guess operational health-safety decisions in a rapidly changing pandemic environment.
These conclusions align with the Sixth Circuit’s prior decision in Kizer v. St. Jude Children’s Research Hospital and the First Circuit’s Melino v. Boston Medical Center.

Factual and Procedural Background

Wise worked as a staff pharmacist from 1999 to 2022. She has long-standing religious objections to medical interventions on healthy individuals and had been exempted from the influenza vaccine since 2013. During COVID-19, the hospital required vaccination or regular testing, later moving to a vaccination mandate with available medical/religious exemptions. Wise sought exemption from both vaccination and testing; the hospital granted the vaccine exemption but denied the testing exemption, emphasizing mitigation responsibilities, patient safety, and the risk that approving one request would necessitate approving similar ones.

Wise tested positive for COVID-19 in February 2022 and was excused from testing for 90 days. When the reprieve expired, she refused to test. After two warnings, she was terminated on June 14, 2022. She sued for Title VII religious discrimination (failure to accommodate) and retaliation. The district court granted summary judgment for the hospital; the Sixth Circuit affirmed.

Analysis

Precedents Cited and Their Influence

Groff v. DeJoy, 600 U.S. 447 (2023): The Supreme Court clarified that “undue hardship” under Title VII requires a showing of substantial increased costs in relation to the conduct of the employer’s particular business, to be assessed in a commonsense, context-specific manner. The Sixth Circuit leaned on Groff’s directive, assessing hardship in the context of a pediatric hospital during a pandemic. The hospital’s patient population and operations framed what counted as a substantial burden.
Virts v. Consolidated Freightways Corp., 285 F.3d 508 (6th Cir. 2002): The court reiterated that an employer need not actually experience the hardship; a reasonable prospect of substantial hardship suffices. This supports foresight-based safety assessments without requiring proof of a realized outbreak.
Cooper v. Oak Rubber Co., 15 F.3d 1375 (6th Cir. 1994): Reasonableness is case-by-case. The court evaluated Wise’s job setting (contained pharmacy, overlapping shifts) and the hospital’s unique patient risks, rather than applying a one-size-fits-all rule.
Kizer v. St. Jude Children’s Research Hospital, No. 24-5207, 2024 WL 4816856 (6th Cir. Nov. 18, 2024): A close factual analogue involving a children’s hospital and a vaccine mandate. The Sixth Circuit there upheld summary judgment for the hospital on undue hardship grounds, highlighting risks to vulnerable pediatric patients. Wise’s hospital offered greater flexibility (testing alternative to vaccination); even so, the Sixth Circuit found undue hardship when an employee sought exemption from both.
Melino v. Boston Medical Center, 127 F.4th 391 (1st Cir. 2025): The First Circuit affirmed a hospital’s denial of a vaccine exemption based on undue hardship in treating medically vulnerable, COVID-positive populations, reinforcing cross-circuit recognition that heightened patient safety risks can satisfy Groff’s standard.
Draper v. U.S. Pipe & Foundry Co., 527 F.2d 515 (6th Cir. 1975): Safety considerations are highly relevant; Title VII does not require subordinating safety to an employee’s religious practice. The panel invoked Draper to underscore why safety-driven refusals to accommodate can be reasonable.
DePriest v. Dep’t of Human Services, 1987 WL 44454 (6th Cir. Oct. 1, 1987) (per curiam): Reinforces that employers need not identify a materialized harm; anticipated substantial risks can establish undue hardship.
Summary judgment authorities: The panel recited standard de novo review and Rule 56 principles (Rose v. State Farm; Kirilenko-Ison; Matsushita), framing how the record was viewed in deciding whether any genuine dispute of material fact existed on undue hardship.

Legal Reasoning

The court assumed, without deciding, that Wise made a prima facie case. It proceeded directly to undue hardship, weighing the hospital’s evidence against Groff’s “commonsense, context” standard:

Patient vulnerability and mission centrality: The hospital’s core function is pediatric care, which disproportionately involves viruses and highly vulnerable patients (e.g., NICU infants, pediatric oncology, immunocompromised children). Protecting these patients was a top priority and integral to the business’s conduct.
Necessity of testing for unvaccinated staff: For unvaccinated employees, routine testing served as the principal mitigation to verify non-infectiousness. Without it, the hospital had “no way” to ensure infected employees were not interacting with colleagues or patient-care areas, creating a substantial safety risk.
Job- and space-specific risk: Wise’s role entailed working long, contained shifts with numerous coworkers and overlapping teams, increasing potential spread within the pharmacy and to staff who interface with patients. This operational reality heightened the risk profile.
Cumulative effects and staffing: At least 35 other employees sought the same exemption. Granting Wise’s request would foreseeably necessitate similar accommodations, “exponentially” increasing risk. Infections among staff had already strained operations, and further spread threatened staffing shortages requiring overtime, staff reassignments, and temporary agency deployment.
Regulatory context: The hospital referenced federal obligations to implement mitigation for unvaccinated staff. While the opinion does not parse specific regulations, these obligations were credited as part of the hardship analysis.

The court rejected Wise’s counterarguments:

No need for realized harm: Title VII does not require proof of actual outbreaks or concrete harms to establish undue hardship; prospective safety risks suffice (Virts; DePriest).
Alleged inconsistency of policies: Differences between testing requirements for vaccinated versus unvaccinated staff, and the 90-day post-infection reprieve, were products of evolving scientific guidance and regulatory shifts. Courts will not engage in “Monday morning quarterbacking” of a hospital’s dynamic safety judgments during a novel pandemic.
Staffing impacts are supported: The hospital introduced evidence and common-sense logic connecting testing refusals to increased infections and staffing shortages in a contained workspace. Those risks are cognizable under Groff as substantial burdens on operations.

On retaliation, the court affirmed summary judgment as well. Although the panel did not set out a distinct retaliation framework, its undue-hardship holding undermines the causation and pretext theories: termination for refusing a lawful, safety-related condition (testing) that the employer was not required to waive is a legitimate, non-retaliatory reason.

Impact and Forward-Looking Significance

Healthcare settings—especially pediatrics: Wise reinforces that in environments serving immunocompromised or infant patients, exemptions that remove both vaccination and testing safeguards can impose undue hardship, even absent proof of actual outbreaks. Hospitals may rely on prospective safety risks, cumulative-request effects, and staffing vulnerabilities to meet Groff.
Testing as a reasonable mitigation: The decision underscores the centrality of testing for unvaccinated staff. A testing exemption, when vaccination has already been excused, can be a bridge too far under Title VII in high-risk care settings.
Cumulative effects matter: Documented evidence that many employees seek similar accommodations is relevant. Groff’s “business context” lens permits employers to show that granting one exemption would predictably lead to many, magnifying risk and operational costs.
No “actual harm” requirement: Anticipatory safety and staffing risks—grounded in evidence and operational logic—can satisfy Groff. This will influence infectious-disease accommodation disputes beyond COVID-19 (e.g., influenza, RSV, measles, TB), particularly in patient-facing or high-density workspaces.
Judicial restraint in dynamic health crises: Courts are unlikely to second-guess day-to-day adjustments to safety policies in rapidly evolving conditions, so long as employers can tie measures to credible guidance and operational needs.
Nonprecedential but persuasive: Although “not recommended for publication,” the reasoning harmonizes with Sixth Circuit authority (Kizer, Virts, Draper) and aligns with the First Circuit (Melino), enhancing its persuasive value in similar disputes.

Complex Concepts Simplified

Title VII religious accommodation: Federal law prohibits religious discrimination and requires employers to reasonably accommodate an employee’s sincerely held religious beliefs, unless doing so would cause undue hardship to the business.
Undue hardship after Groff: The Supreme Court in Groff clarified that “undue hardship” means a substantial increased cost or burden in relation to the business’s operations, assessed in context. It is no longer enough for employers to point to a “more than de minimis” cost; they must show a substantial burden. Safety risks, regulatory obligations, and foreseeable staffing disruptions can qualify when credibly shown.
Prospective hardship: Employers need not wait for a harm to materialize. If evidence shows that granting the accommodation would likely cause substantial safety or operational burdens, undue hardship is met.
Summary judgment: A case can be resolved without trial if there is no genuine dispute of material fact and the movant is entitled to judgment as a matter of law. Courts view evidence in the nonmovant’s favor but will grant judgment if no reasonable jury could find otherwise.
“Not recommended for publication”: The decision is nonprecedential within the circuit, meaning it does not bind future panels. It can still be cited for persuasive value where rules permit.

Practical Takeaways

For healthcare employers:
- Document the specific safety and operational risks tied to the employee’s role and workspace (e.g., patient vulnerability, cohesion of teams, density of interactions, overlap of shifts).
- Explain why the requested accommodation would undermine essential mitigations (e.g., why testing is indispensable for unvaccinated staff).
- Record cumulative-request data and model expected operational impacts (staffing shortages, cross-coverage, temporary agency use).
- Show alignment with evolving public health guidance and any applicable federal or state requirements.
For employees seeking accommodation:
- Articulate the belief and its conflict with the policy clearly.
- Propose workable alternatives that address core safety concerns; be prepared that an employer may reasonably grant some accommodations (e.g., vaccine exemption) while denying others (e.g., testing exemption) where safety and operations demand it.
- Recognize that in high-risk care settings, courts give weight to credible, role-specific safety and staffing concerns.

Conclusion

Wise applies Groff’s post-2023 “undue hardship” standard in a pediatric hospital during a pandemic and holds that a testing exemption for an unvaccinated employee can impose an undue hardship where the employer demonstrates substantial, foreseeable risks to vulnerable patients and critical operations. The court emphasizes that safety need not be subordinated to religious practice and that employers are not required to wait for concrete harms to materialize, especially when cumulative requests and staffing realities magnify the risks.

Although nonprecedential, the decision aligns with Sixth Circuit and First Circuit authority and offers a clear blueprint for assessing religious accommodations in healthcare: (1) focus on the employer’s mission and patient risk profile, (2) tie the requested accommodation to concrete safety and operational burdens, (3) consider cumulative effects, and (4) recognize that dynamic, good-faith reliance on evolving guidance will not be second-guessed. As infectious-disease management remains a recurring operational challenge, Wise is likely to inform courts and parties navigating the tension between religious accommodation and patient safety in high-risk clinical settings.