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,

(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.”

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.,

, 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,

(4th Cir.

2019) (quoting Henry v. Purnell,

(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.”

(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.,

, 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,

(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.,

(4th Cir. 2008) (citing Chalmers,

) (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.”

(quoting Chalmers,

)

(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,

(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.

A.

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,

(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,

(citing

Hardison,

); see, e.g., Firestone Fibers,

(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,

. 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.”

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.”

. 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.

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.

.

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.

. 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,

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,

,

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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.,

, 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,”

, 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,

(3d Cir. 2009).

For example, Groff confirmed that reworking schedules in contradiction to a bona fide

seniority system was an undue hardship.

. 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,

, 1220 (9th Cir. 2025); cf. Rodrique v. Hearst Commc’ns,

Inc.,

(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,

, 1157 (D. Or. 2024) (quoting Jean-Pierre

v. Naples Cmty. Hosp., Inc.,

, 828 (11th Cir. 2020) (per curiam)).

B.

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,

(“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,

, 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.,

, 1136 (C.D. Cal. 2023), aff’d, No. 23-4340,

(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

(10)(A) (defining “undue hardship”

under the ADA as “an action requiring significant difficulty or expense”), with Groff,

(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,

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.

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