Health Law Daily Wrap Up, HEALTH CARE EMPLOYMENT ISSUES—4th Cir.: Hospital demonstrated undue hardship in religious accommodation case concerning COVID-19 vaccination, (Oct 24, 2025)

By Cathleen Calhoun, J.D.

“Employers can more easily show undue hardship when considering religious-accommodation requests under Title VII than when considering medical-accommodation requests under the ADA.”

Affirming a lower court’s grant of summary judgment in a case of religious discrimination brought by a hospital employee who was fired after refusing to receive the COVID-19 vaccination, the Fourth Circuit found that the hospital showed the necessary hardship required to refuse a religious accommodation. The employee had undisputedly established a prima facie case of failure to accommodate under Title VII, so the only question became whether the religious accommodation would have caused the hospital undue hardship. The court examined the standards, noted the difference between the standards of religious and medical accommodations, and found that in light of the employee’s front-facing role, and her interaction with medically at-risk patients, the religious accommodation was too much of a burden (Hall v. Sheppard Pratt Health System, Inc., No. 24-2048 (4th Cir. Oct. 21, 2025)).

The employee served as an Admissions Coordinator for the Center for Eating Disorders at Sheppard Pratt Health System (Sheppard Pratt), and that role included greeting patients and their families, ensuring completion of intake paperwork, and answering any questions. She was terminated from her employment in 2021 after refusing the COVID-19 vaccination.

Exemptions. After experiencing COVID-19 outbreaks, Sheppard Pratt Health System announced that all employees needed to receive their first dose of the vaccine by September 1, 2021, and it directed employees to submit requests for medical or religious exemptions as necessary. Under its policy, Sheppard Pratt granted religious exemptions “based on a sincerely held religious belief.” If an employee’s job could not be accommodated remotely, the HR department would explore if the employee might be qualified for another open position that could be performed remotely. The employee did not seek such action. The process was different for medical exemptions. Employees with medical contraindications could request a medical exemption by submitting a Medical Exemption Form, which was then reviewed by a third-party doctor. If approved, employees with medical exemptions who could not work remotely were required to wear masks and test for COVID-19 weekly.

Accommodation standards. In analyzing the standards required for religious accommodations, the court noted that religious accommodations under Title VII need not be viewed in isolation. Specifically, the court stated that it agreed with other circuits that have concluded, after the U.S. Supreme Court’s 2023 decision in Groff v. DeJoy, that non-economic costs can also include threats to the health and safety of employees and the people they serve. According to the court, Groff specifically declined to adopt the more stringent definition of undue hardship from the ADA, which requires employers to show a “significant difficulty or expense” to deny a medical accommodation. According to the court, “this means that employers can more easily show undue hardship when considering religious-accommodation requests under Title VII than when considering medical-accommodation requests under the ADA.”

Undue hardship. The court found that Sheppard Pratt presented undisputed evidence that allowing the employee to remain unvaccinated posed an unacceptably high risk to patient safety. The employee did not dispute the efficacy of the COVID-19 vaccine, nor its ability to slow transmission of the virus. “Sheppard Pratt understandably did not want to risk exposure of those patients to the dangerous effects of COVID-19, and contemporaneous evidence showed that vaccines were more effective in preventing transmission than masking and testing weekly,” the court noted. Also, evidence was put forward that allowing the hundreds of those who requested religious exemptions to remain unvaccinated would have increased the risk of a COVID-19 outbreak, and COVID-19 outbreaks triggered lockdown procedures that were detrimental to patients. In lockdowns, patients were socially isolated, and that was particularly detrimental to those with eating disorders. Economic costs were involved as well since new patients were not admitted during lockdowns.

The employee’s argument that Sheppard Pratt should instead have offered her the same accommodation it offered to those requesting medical exemptions under the ADA—masking and weekly testing—failed. The court noted that in considering this alternative, Sheppard Pratt presented undisputed evidence that these methods were less effective than vaccination at preventing COVID-19 transmission. “The law does not require Sheppard Pratt to treat religious and medical exemptions the same,” the court noted. Referring to Groff, the court stated that “undue hardship” under Title VII means that the “accommodation would result in substantial increased costs in relation to the conduct of its particular business.” As a result, the court found that the hospital system easily demonstrated the requisite undue hardship necessary to deny the religious accommodation request under Title VII. Summary judgment was affirmed.

The case is No. 24-2048.

Judge: Wynn, J.

Attorneys: Theresa Dawn Truitt Kraft (WTK & Associates) for Carolyn Hall. Paul D. Burgin (Ogletree, Deakins, Nash, Smoak & Stewart) for Sheppard Pratt Health System.

Companies: Sheppard Pratt Health System

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