USCA4 Appeal: 24-2048 Doc: 34 Filed: 10/21/2025 Pg: 1 of 14
PUBLISHED
UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT
No. 24-2048
CAROLYN HALL,
Plaintiff - Appellant,
v.
SHEPPARD PRATT HEALTH SYSTEM, INC.,
Defendant - Appellee.
Appeal from the United States District Court for the District of Maryland, at Baltimore. Adam B. Abelson, District Judge. (1:22-cv-03261-MABA)
Argued: September 9, 2025 Decided: October 21, 2025
Before DIAZ, Chief Judge, and WYNN and HARRIS, Circuit Judges.
Affirmed by published opinion. Judge Wynn wrote the opinion, in which Chief Judge Diaz and Judge Harris joined.
ARGUED: Theresa Dawn Truitt Kraft, WILT TOIKKA KRAFT LLP, Washington, D.C., for Appellant. Paul D. Burgin, OGLETREE DEAKINS, Baltimore, Maryland, for Appellee. ON BRIEF: Garrick M. Ross, OGLETREE DEAKINS, Baltimore, Maryland, for Appellee. USCA4 Appeal: 24-2048 Doc: 34 Filed: 10/21/2025 Pg: 2 of 14
WYNN, Circuit Judge:
Under Title VII, an employer must provide for a religious accommodation unless
doing so would impose an undue hardship on the employer, a standard that the Supreme
Court recently clarified in Groff v. DeJoy, 600 U.S. 447 (2023).
In this case, Carolyn Hall was terminated from her employment at a hospital after
she refused to be vaccinated against COVID-19 during the height of the pandemic. She
sued her former employer, alleging that it should have granted her a religious exemption
from its vaccine requirement.
Because the district court properly concluded that exempting Hall from this
requirement would have jeopardized patient safety and increased the risk of disruptive
outbreaks in a sensitive environment, we affirm the district court’s grant of summary
judgment in favor of the hospital.
I.
A.
On this appeal from an order granting summary judgment, we recite the facts in the
light most favorable to Hall, the nonmovant.
Hall served as an Admissions Coordinator for the Center for Eating Disorders at
Sheppard Pratt Health System in Maryland. In that role, she was responsible for admitting
patients to the unit. Hall would greet patients and their families in the lobby, make sure
they completed intake paperwork, and answer any questions they had. This welcome
process sometimes included a “long talk,” especially if the patient was a minor
accompanied by concerned parents. J.A. 192. Given these responsibilities, Hall
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acknowledged that her job “could not be performed at home 100 percent of the time,” J.A.
210–11, although Sheppard Pratt had previously allowed her to work remotely on a
temporary basis when she contracted COVID-19. Hall also shared a small office with
another employee and regularly interacted with additional Sheppard Pratt employees.
B.
In response to the ongoing COVID-19 pandemic, Sheppard Pratt established
protocols to protect patients and staff, relying on guidance from the CDC and the Maryland
Department of Health. All employees, regardless of vaccination status, were required to
wear masks. A positive COVID-19 test from a patient would trigger additional protocols.
These outbreak protocols included an isolation procedure, which required Sheppard Pratt
to hire more expensive temporary staff to avoid having the same staff interact with patients
who had tested positive and then with other patients who had not. Staff working with
patients who tested positive needed to wear additional personal protective equipment.
Sheppard Pratt also suspended communal patient activities during an outbreak, which
disrupted treatment.
Sheppard Pratt was especially attuned to preventing the transmission of COVID-19
in the Center for Eating Disorders. Due to their eating disorders, patients in this unit were
medically vulnerable, faced high risks of mortality, and often came to the unit after long
periods of hospitalization. Because patients with eating disorders often present with other
medical issues, including mental health disorders, malnourishment, and cardiac conditions,
these patients were particularly at risk from the effects of COVID-19.
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Additionally, the treatment program in that unit required numerous instances of
close contact between patients and staff. For example, patients ate meals with clinicians
present so that the clinicians could provide treatment as to patients’ eating habits, and
patients could not use the restroom without a staff member present to ensure that the patient
did not purge. The treatment program in the Center also placed “extreme importance” on
“human interaction and group programming,” which were interrupted when a patient in the
unit tested positive for COVID-19. J.A. 53–54.
Despite its protocols, between September 30, 2020, and November 12, 2021,
Sheppard Pratt experienced twenty-two COVID-19 outbreaks, each lasting between 10 and
38 days.
In August 2021, COVID-19 cases and hospitalizations in Maryland were surging,
prompting the Maryland Secretary of Health to issue a directive requiring all employees of
healthcare facilities like Sheppard Pratt to be vaccinated against COVID-19 by September
1, 2021. In response, Sheppard Pratt 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.” J.A. 73. The policy required the staff member to submit a request
form specifying their religious objection and sometimes required the staff member to
submit supporting documentation. Sheppard Pratt would then “consider each request on a
case-by-case basis” and might deny the request if it “determine[d] that the risk posed by an
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unvaccinated staff member [could not] be mitigated and/or constitute[d] an ‘undue
hardship’ under state and federal law.” Id.
When evaluating each religious exemption request, Sheppard Pratt Vice President
of Human Resources Karen Robertson-Keck would speak with the employee’s manager to
discuss job duties and explore whether the job could be performed without in-person
contact. Robertson-Keck also met with the employee requesting an exemption to discuss
proposed accommodations. If an employee’s job could not be accommodated remotely,
Robertson-Keck would explore with the employee whether they might be qualified for
another open position that could be performed remotely. If an individual’s religious
exemption was not granted and they refused to be vaccinated, their employment was
terminated, but they remained eligible for rehire. In all, over two hundred Sheppard Pratt
employees requested religious exemptions, and two dozen were approved.
Sheppard Pratt followed a different process 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. This accommodation was not offered to those requesting a
religious exemption. In all, about one hundred Sheppard Pratt employees requested medical
exemptions, and a little over half were approved.
C.
Hall submitted a request for a religious exemption on August 30, 2021, supported
by a letter from her pastor. Per Sheppard Pratt’s religious-accommodation procedures,
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Robertson-Keck first met with Hall’s supervisor to assess whether Hall’s role could be
performed without in-person interaction. She then met with Hall, her supervisor, and the
Director of Employee Relations. Sheppard Pratt ultimately determined that, given her role,
Hall’s requested exemption could not be accommodated. Robertson-Keck told Hall she
could apply for other positions that she would be able to perform remotely without being
vaccinated, but Hall never did so. Sheppard Pratt terminated Hall effective November 12,
2021.
Hall filed a Charge of Discrimination with the EEOC and received a Right to Sue
letter. She filed suit in federal court, alleging violations of Title VII of the Civil Rights Act
of 1964—specifically, that Sheppard Pratt had discriminated against her because of her
religious beliefs.
Sheppard Pratt moved for summary judgment, and the district court granted the
motion. Hall v. Sheppard Pratt Health Sys., Inc., 749 F. Supp. 3d 532, 550 (D. Md. 2024).
Hall timely appealed.
II.
We review the district court’s grant of summary judgment de novo, “using the same
standard applied by the district court.” Brooks v. Johnson, 924 F.3d 104, 111 (4th Cir.
2019) (quoting Henry v. Purnell, 652 F.3d 524, 531 (4th Cir. 2011)). “In doing so, we
recognize that a court should grant summary judgment only if, taking the facts in the best
light for the nonmoving party, no material facts are disputed and the moving party is
entitled to judgment as a matter of law.” Id. (cleaned up).
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III.
“Title VII of the Civil Rights Act of 1964 makes it unlawful for an employer ‘to
discharge any individual, or otherwise to discriminate against any individual . . . because
of such individual’s . . . religion.’” Barnett v. Inova Health Care Servs., 125 F.4th 465, 470
(4th Cir. 2025) (quoting 42 U.S.C. § 2000e-2(a)(1)). Employees may sue under Title VII
using either a “disparate treatment” or “failure to accommodate” theory, Chalmers v. Tulon
Co. of Richmond, 101 F.3d 1012, 1017 (4th Cir. 1996), but Hall presses only a failure-to-
accommodate claim on appeal. 1
To assess a claim that an employer failed to accommodate an employee’s religion
in violation of Title VII, courts employ a burden-shifting framework. First, the plaintiff
must establish a prima facie claim. E.E.O.C. v. Firestone Fibers & Textiles Co., 515 F.3d
307, 312 (4th Cir. 2008) (citing Chalmers, 101 F.3d at 1019) (listing requirements).
Second, if the employee successfully establishes her prima facie case, “the burden then
shifts to the employer to show that it could not reasonably accommodate the plaintiff’s
religious needs without undue hardship.” Id. (quoting Chalmers, 101 F.3d at 1019)
(cleaned up).
Sheppard Pratt concedes that Hall established a prima facie case. Therefore, the only
question before this Court is whether Sheppard Pratt successfully demonstrated that
1 The district court struggled to understand whether Hall was also bringing a separate disparate-treatment claim under Title VII but nevertheless granted summary judgment to Sheppard Pratt on that claim. Hall, 749 F. Supp. 3d at 548–50. Hall does not discuss this matter in her opening brief, so we do not address it here. See Stokes v. Stirling, 64 F.4th 131, 137 (4th Cir. 2023). 7 USCA4 Appeal: 24-2048 Doc: 34 Filed: 10/21/2025 Pg: 8 of 14
accommodating Hall’s requested exemption from the vaccine mandate would cause it
undue hardship, entitling it to summary judgment. We agree with the district court that it
did.
We first define undue hardship under Title VII, then apply that standard to Hall’s
exemption request.
Under Title VII, an employer need not grant a religious accommodation if doing so
would create an “undue hardship on the conduct of the employer’s business.” 42 U.S.C.
§ 2000e(j). The statute does not define “undue hardship,” but the Supreme Court has
fleshed out the term’s meaning.
In Trans World Airlines, Inc. v. Hardison, 432 U.S. 63 (1977), the Supreme Court
described the undue hardship standard in several different ways. In the ensuing years, many
lower courts—including this one—coalesced around an understanding of Hardison that
read one line from that opinion as setting the standard, interpreting “‘undue hardship’ to
mean any effort or cost that is ‘more than . . . de minimis.’” Groff, 600 U.S. at 454 (citing
Hardison, 432 U.S. at 84); see, e.g., Firestone Fibers, 515 F.3d at 312 (applying the more-
than-de-minimis standard in this Court).
Recently, however, in Groff v. DeJoy, the Supreme Court “clarified” that lower
courts had misunderstood Hardison. Groff, 600 U.S. at 473. Relying on “costs and
expenditures that are . . . ‘de minimis,’ which is to say, so ‘very small or trifling’ that . . .
they are not even worth noticing,” is far too weak a standard given the statute’s reference
to “undue hardship.” Id. at 464 (quoting Black’s Law Dictionary 388 (5th ed. 1979)).
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Instead, under the correct standard, “an employer must show that the burden of granting an
accommodation would result in substantial increased costs in relation to the conduct of its
particular business.” Id. at 470. In evaluating whether an employer has satisfied this test,
courts must “take[] into account all relevant factors in the case at hand, including the
particular accommodations at issue and their practical impact in light of the nature, size
and operating cost” of the employer. Id. at 470–71 (cleaned up). An employer puts its
strongest foot forward when it considers not only the employee’s suggested
accommodation but also other potential accommodations. Id. at 473.
At the same time, Groff specifically declined to adopt the more stringent definition
of undue hardship from the Americans with Disabilities Act (“ADA”), which requires
employers to show a “significant difficulty or expense” to deny a medical accommodation.
Id. at 471. 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.
Importantly, because Groff clarified Hardison rather than overruling it, Hardison
and lower court cases applying it remain valid to the extent they do not conflict with Groff.
Relevant here, Hardison established that religious accommodations under Title VII need
not be viewed in isolation. Courts may, and should, look to the undue hardship a particular
religious accommodation would have in the aggregate if granted to all similarly situated
employees. See Hardison, 432 U.S. at 84 n.15 (chiding the dissent for failing to “take
account of the likelihood that a company . . . may have many employees whose religious
observances” require a similar accommodation); Jordan v. N.C. Nat’l Bank, 565 F.2d 72,
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76 (4th Cir. 1977) (noting a grant of a particular accommodation “would obligate the bank
to provide it for all of its employees and entail extra expense”), overruled on other grounds
by E.E.O.C. v. Ithaca Indus., Inc., 849 F.2d 116, 119 n.3 (4th Cir. 1988).
Additionally, in accordance with Groff’s command that courts consider “all relevant
factors in the case at hand, including the particular accommodations at issue and their
practical impact,” 600 U.S. at 470, we emphasize that undue hardship can come from
“[b]oth economic and non-economic costs” that the employer would incur if it granted the
religious accommodation. Webb v. City of Philadelphia, 562 F.3d 256, 260 (3d Cir. 2009).
For example, Groff confirmed that reworking schedules in contradiction to a bona fide
seniority system was an undue hardship. 600 U.S. at 462. And we agree with other circuits
that have concluded, after Groff, that non-economic costs can also include threats to the
health and safety of employees and the people they serve. See Petersen v. Snohomish Reg’l
Fire & Rescue, 150 F.4th 1211, 1220 (9th Cir. 2025); cf. Rodrique v. Hearst Commc’ns,
Inc., 126 F.4th 85, 91 (1st Cir. 2025).
We find particularly helpful the Ninth Circuit’s recent analysis in Petersen v.
Snohomish Regional Fire & Rescue. In that case, firefighters and paramedics requested
religious exemptions to the COVID-19 vaccine mandate. The Ninth Circuit concluded that
the employer would have incurred “significant health and safety costs by allowing
unvaccinated firefighters to continue working, even with accommodations.” Petersen, 150
F.4th at 1220. The court emphasized that the employer needed the vaccine mandate “to
ensure employee and public safety,” especially for a workforce that served “persons in the
public needing emergency, even life-saving, services.” Id. Other lower courts have agreed
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that the undue hardship of having unvaccinated employees is particularly acute in a health
care setting, where “the employer’s business involves the protection of lives.” Lavelle-
Hayden v. Legacy Health, 744 F. Supp. 3d 1135, 1157 (D. Or. 2024) (quoting Jean-Pierre
v. Naples Cmty. Hosp., Inc., 817 F. App’x 822, 828 (11th Cir. 2020) (per curiam)).
With this clarified standard in mind, we turn to whether granting Hall a religious
exemption would have constituted an undue hardship for Sheppard Pratt. Viewing the
evidence in the light most favorable to Hall, we agree with the district court that Sheppard
Pratt satisfied its burden to show that it would have.
First and foremost, Sheppard Pratt put on undisputed evidence that allowing Hall to
remain unvaccinated posed an unacceptably high risk to patient safety. As her Complaint
makes clear, Hall did not dispute the efficacy of the COVID-19 vaccine, nor its ability to
slow transmission of the virus.
And yet, the record is clear that Hall’s position required her to interact with
medically compromised patients. 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. Cf. Rodrique, 126 F.4th at 91 (“Because the record
demonstrates that [the employer] relied ‘on the objective, scientific information available
to [it],’ with particular attention to ‘the views of public health authorities,’ we hold that it
acted reasonably when it determined that vaccinated employees are less likely to transmit
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COVID-19 than unvaccinated employees.” (quoting Bragdon v Abbott, 524 U.S. 624, 649–
50 (1998))).
Sheppard Pratt also put forth undisputed evidence that allowing Hall and the
hundreds of others who requested religious exemptions to remain unvaccinated would have
increased the risk of a COVID-19 outbreak, which triggered lockdown procedures. Those
lockdown procedures were detrimental to patients. For example, during lockdowns,
patients lost access to sorely needed social time, leading to social isolation that is especially
harmful to patients with eating disorders. The procedures also caused direct economic harm
to Sheppard Pratt because the Center for Eating Disorders would temporarily stop
admitting new patients.
Hall’s refusal to be vaccinated put her fellow coworkers at risk of contracting the
virus, as well. Courts have found that, even post-Groff, such a safety risk to fellow
employees is independently a cognizable undue hardship. Bordeaux v. Lions Gate Ent.,
Inc., 703 F. Supp. 3d 1117, 1136 (C.D. Cal. 2023), aff’d, No. 23-4340, 2025 WL 655065
(9th Cir. Feb. 28, 2025); see also Petersen, 150 F.4th at 1220 (9th Cir. 2025 (noting
“firefighters work in group settings, interfacing constantly with coworkers and the public,”
such that allowing workers to be unvaccinated was a hardship on the fire and rescue team’s
“own workforce”). But Sheppard Pratt also suffered direct financial harm when it was
forced to replace ill workers with more expensive temporary hires at a time when health
care worker shortages were already particularly acute.
Sheppard Pratt also considered alternative arrangements. It considered whether
Hall’s position could be performed remotely and determined that it could not, a conclusion
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with which Hall herself agreed. 2 It even offered to allow Hall to apply to other positions
within the hospital system, an invitation Hall declined.
Hall argues 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. But Sheppard Pratt considered this alternative and put forth
undisputed evidence that these methods were less effective than vaccination at preventing
COVID-19 transmission.
As discussed, the law does not require Sheppard Pratt to treat religious and medical
exemptions the same. Compare 42 U.S.C. § 12111(10)(A) (defining “undue hardship”
under the ADA as “an action requiring significant difficulty or expense”), with Groff, 600
U.S. at 470 (holding 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”). That diverging standard is why an employer like Sheppard Pratt may deny a
religious accommodation request even if the employer has a history of granting that same
request as a medical accommodation. Here, it is enough that Sheppard Pratt put forth
undisputed evidence that granting Hall a religious exemption would have resulted in the
“substantial increased costs” that would result from outbreaks in the hospital, replacement
2 For the first time on appeal, Hall also argues that Sheppard Pratt should have considered erecting plexiglass in the admissions area to accommodate her. We decline to consider this unpreserved argument. But even if we did, Hall put forth no evidence that plexiglass would have slowed transmission to patients, nor would it address the independent risk to other employees who would interact with Hall when she was not behind plexiglass. 13 USCA4 Appeal: 24-2048 Doc: 34 Filed: 10/21/2025 Pg: 14 of 14
of ill employees with higher-cost temporary employees, and acute threats to the physical
safety of Sheppard Pratt’s staff and patients.
It is likely that granting even Hall’s single religious exemption would have
constituted an undue hardship for the hospital system. But we need not reach that question
because Sheppard Pratt also rightly considered the effect of granting not just Hall’s request
but also those of the significant number of other employees requesting a religious
exemption across the hospital system. See Hardison, 432 U.S. at 84 n.15. Allowing over
two hundred religious-exemption claimants to remain unvaccinated would have
unacceptably increased the risk of COVID-19 transmissions and outbreaks.
In all, on this record, considering the “practical impact” of granting Hall’s request
“in light of the nature” of Sheppard Pratt’s business, Groff, 600 U.S. at 470–71, the hospital
system easily demonstrated the requisite undue hardship necessary to deny Hall’s religious
accommodation request under Title VII. The district court did not err in granting Sheppard
Pratt summary judgment.
IV.
For the foregoing reasons, the district court’s judgment is
AFFIRMED.